Effectiveness and Safety of IV Rt-PA Treatment in Chinese AIS Patients Aged Above 80 Years: a Real-world Study
Conditions: Stroke
Sponsor: Boehringer Ingelheim

ABCD 
001-MCS-90-118_RD-23 (2.0) / Saved on: 02 Jul 2020
TITLE PAGE
Non-Interventional Study (NIS) Protocol
TITLE PAGE
Document Number: 
c36563700-01
BI Study Number: 
0135-0349
BI Investigational 
Product(s):
Actilyse® (Alteplase) 
Title: 
Effectiveness and safety of IV rt-PA treatment in Chinese AIS patients 
aged above 80 years: a real-world study 
Brief lay title: 
Alteplase treatment in elderly AIS patients
Protocol version 
identifier: 
1.0
Date of last version of 
protocol: 
Not applicable
PASS:
No
EU PAS register 
number: 
EUPAS41540 
Active substance: 
Alteplase
Medicinal product:
Actilyse® (Alteplase)
Product reference:
Not applicable
Procedure number:
Not applicable
Marketing authorisation 
holder(s):
Joint PASS: 
No
Research question and 
objectives:
Primary objective:
x
To compare the 1-year favourable neurological functional
outcome (as measured by modified Rankin Scale [mRS] score ,
defined as mRS 0-1) of Chinese AIS patients aged > 80 years
who received IV rt-PA treatment within 4.5 hours of symptom
onset versus those who arrived or were admitted to the hospital
within 4.5 hours of symptom onset and did not receive
reperfusion therapy.

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Secondary objectives:
x
To compare in-hospital and other 1-year clinical outcomes
(including any intracranial haemorrhage (ICH), all-cause
mortality during hospitalisation, independence (mRS 0-2)
at 1 year, distribution of mRS score at 1 year, and all-
cause mortality at 1 year. Detailed description of these
outcomes are provided in the section “secondary outcomes”)
of elderly AIS patients who received IV rt-PA treatment within
4.5 hours of symptom onset versus those who arrived or were
admitted to the hospital within 4.5 hours of symptom onset and
did not receive any reperfusion therapy.
x
To compare the baseline characteristics of AIS patients
aged > 80 years treated with IV rt-PA within 4.5 hours of
symptom onset versus AIS patients aged >80 years who arrived
or were admitted to the hospital within 4.5 hours of symptom
onset and did not receive reperfusion treatment in Zhejiang
Stroke Quality Control Centre (ZSQCC) platform to evaluate
potential channelling bias.
Country(-ies) of study:
China 
Author: 
In case of PASS, add:
MAH contact person: 
Not applicable
In case of PASS, add: 
<EU-QPPV:>
Not applicable
In case of PASS, add: 
<Signature of EU-
QPPV:>
Not applicable
Date: 
6HS 2021
Page 1 of 42 
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© 2021 Boehringer Ingelheim Group of companies. All rights reserved.
This document may not - in full or in part - be passed on, reproduced, published or otherwise used without prior written permission

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1.
TABLE OF CONTENTS
TITLE PAGE .................................................................................................................. 1 
1.
TABLE OF CONTENTS....................................................................................... 3 
2.
LIST OF ABBREVIATIONS................................................................................ 5 
3.
RESPONSIBLE PARTIES.................................................................................... 6 
4.
ABSTRACT........................................................................................................... 7 
5.
AMENDMENTS AND UPDATES..................................................................... 13 
6.
MILESTONES..................................................................................................... 14 
7.
RATIONALE AND BACKGROUND................................................................ 15 
8.
RESEARCH QUESTION AND OBJECTIVES ................................................. 17 
9.
RESEARCH METHODS .................................................................................... 18 
9.1 
STUDY DESIGN ............................................................................................ 18 
9.2 
SETTING ........................................................................................................ 19 
9.2.1 
Study sites ............................................................................................... 19 
9.2.2 
Study population ..................................................................................... 19 
9.2.3 
Study visits .............................................................................................. 19 
9.2.4 
Study discontinuation .............................................................................. 19 
9.3 
VARIABLES .................................................................................................. 20 
9.3.1 
Exposures ................................................................................................ 20 
9.3.2 
Outcomes ................................................................................................. 20 
9.3.2.1 
Primary outcome .............................................................................. 20 
9.3.2.2 
Secondary outcomes ......................................................................... 20 
9.3.3 
Covariates ................................................................................................ 20 
9.4 
DATA SOURCES ........................................................................................... 21 
9.4.1 
ZSQCC platform ..................................................................................... 21 
9.4.2 
CSCA platform ........................................................................................ 21 
9.5 
STUDY SIZE .................................................................................................. 22 
9.6 
DATA MANAGEMENT ................................................................................ 22 
9.7 
DATA ANALYSIS ......................................................................................... 22 
9.7.1 
Main analysis ........................................................................................... 23 
9.7.3 
Safety analysis ......................................................................................... 24 
9.8 
QUALITY CONTROL ................................................................................... 24 

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9.9 
LIMITATIONS OF THE RESEARCH METHODS ...................................... 24 
9.10 
OTHER ASPECTS ......................................................................................... 25 
9.10.1 
Data quality assurance ............................................................................. 25 
9.10.2 
Study records ........................................................................................... 25 
9.10.2.1 
Source documents ............................................................................ 25 
9.10.2.2 
Direct access to source data and documents .................................... 25 
10.
PROTECTION OF HUMAN SUBJECTS .......................................................... 26 
10.1 
STUDY APPROVAL AND PATIENT INFORMATION ............................. 26 
10.2 
STATEMENT OF CONFIDENTIALITY ...................................................... 26 
11.
MANAGEMENT AND REPORTING OF ADVERSE EVENTS/ADVERSE
REACTIONS ....................................................................................................... 27 
12.
PLANS FOR DISSEMINATING AND COMMUNICATING STUDY RESULTS
 ............................................................................................................................. 28 
13.
REFERENCES .................................................................................................... 29 
13.1 
PUBLISHED REFERENCES ......................................................................... 29 
13.2 
UNPUBLISHED REFERENCES ................................................................... 31 
ANNEX 1. LIST OF STAND-ALONE DOCUMENTS .............................................. 32 
ANNEX 2. ENCEPP CHECKLIST FOR STUDY PROTOCOLS .............................. 33 
ANNEX 3. ADDITIONAL INFORMATION .............................................................. 40 
ANNEX 4. REVIEWERS AND APPROVAL SIGNATURES ................................... 41 

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2.
LIST OF ABBREVIATIONS
AIS
Acute Ischaemic Stroke
ASD
Absolute Standardised Difference
BI
Boehringer Ingelheim
CDE
Centre for Drug Evaluation
CSCA
Chinese Stroke Centre Alliance
DMRP
Data Management and Review Plan
GPP
Good Pharmacoepidemiology Practice
ICH
Intracranial Haemorrhage
IEC
Independent Ethics Committee
IRB
Institutional Review Board
IV
Intravenous
IVT
Intravenous Thrombolysis
mRS
Modified Rankin Scale
NIHSS
National Institutes of Health Stroke Scale
NIS
Non-Interventional Study(ies)
PS
Propensity Score
PSM
Propensity Score Matching
RCT
Randomised Controlled Trials
RR
Relative Risk
rt-PA
Recombinant Tissue Plasminogen Activator
RWE
Real-World Evidence
SOP
Standard Operation Procedure
ZSQCC
Zhejiang Stroke Quality Control Centre

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3.
RESPONSIBLE PARTIES
Boehringer Ingelheim Contact Person:
Contact details: 
 Investigator:
Contact details: 

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4.
ABSTRACT
Name of company:
Boehringer Ingelheim
Name of finished medicinal 
product:  
Actilyse®
Name of active ingredient:
Alteplase
Study
number:
Version/Revision:
Version/Revision date:
Protocol date:
6HS 2021
0135-0349
1.0
NA
Title of study:
Effectiveness and safety of IV rt-PA treatment in Chinese AIS patients aged 
above 80 years: a real-world study 
Rationale and 
background:
Actilyse® was first approved for the treatment of acute ischaemic stroke 
(AIS) for patients aged 18-80 years. Data from recent studies have shown 
that patients aged > 80 years may also benefit from intravenous (IV) 
recombinant tissue plasminogen activator (rt-PA) when given within 
4.5 hours of symptom onset. 
All countries in the European Union including Germany, Austria and 
Belgium have successively approved Actilyse® to remove the age restriction 
of 80 years since Jun 2018. Most of the data supporting this clinical overview 
came from western countries. As there is limited data regarding the safety or 
effectiveness of IV rt-PA among Chinse AIS patients aged > 80 years, the 
age restriction has not been removed yet by National Medical Products 
Administration. However, Chinese Guidelines for Diagnosis and Treatment 
of AIS 2014 and 2018 removed the age restriction of 80 years in the 
recommendations for intravenous thrombolysis (IVT) with alteplase within 
3 hours and 3 to 4.5 hours of stroke onset, respectively. In addition, Chinese 
AIS patients aged > 80 years have been treated with IV thrombolytic therapy 
in clinical practice according to local guidelines.
We propose to use the Zhejiang Stroke Quality Control Centre (ZSQCC) 
platform data to conduct a retrospective study comparing the 1-year clinical 
outcome of IV rt-PA treated patients versus non-reperfusion elderly 
(> 80 years) AIS patients. 
Research 
question and 
objectives:
Research question: Can Chinese AIS patients older than 80 years benefit 
from IV rt-PA treatment within 4.5 hours of symptom onset in a real-world 
clinical setting?
Primary objective:
x
To compare the 1-year favourable neurological functional outcome
(as measured by modified Rankin Scale [mRS] score, defined as
mRS 0-1) of Chinese AIS patients aged > 80 years receiving IV rt-
PA treatment within 4.5 hours of symptom onset versus those who

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Name of company:
Boehringer Ingelheim
Name of finished medicinal 
product:  
Actilyse®
Name of active ingredient:
Alteplase
Study
number:
Version/Revision:
Version/Revision date:
Protocol date:
6HS 2021
0135-0349
1.0
NA
arrived or were admitted to the hospital within 4.5 hours of symptom 
onset and did not receive reperfusion therapy.
Secondary objectives: 
x
To compare in-hospital and other 1-year clinical outcomes (including
any intracranial haemorrhage (ICH), all-cause mortality during
hospitalisation, independence (mRS 0-2) at 1 year, distribution
of mRS score at 1 year, and all-cause mortality at 1 year.
Detailed description of these outcomes are provided in the
section “secondary outcomes”) of elderly AIS patients receiving IV
rt-PA treatment within 4.5 hours of symptom onset versus those who
arrived or were admitted to the hospital within 4.5 hours of symptom
onset and did not receive any reperfusion therapy.
x
To compare the baseline characteristics of AIS patients
aged > 80 years treated with IV rt-PA within 4.5 hours of symptom
onset versus AIS patients aged > 80 years who arrived or were
admitted to the hospital within 4.5 hours of symptom onset and did
not receive reperfusion treatment in ZSQCC platform to evaluate
potential channelling.
Study design:
This is a NIS based on existing data from the ZSQCC platform.
Population:
Inclusion criteria:
x
Patients registered in the ZSQCC platform from Jan 2017 to
Mar 2020
x
> 80 years of age
x
Diagnosed with AIS at admission

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Name of company:
Boehringer Ingelheim
Name of finished medicinal 
product:  
Actilyse®
Name of active ingredient:
Alteplase
Study
number:
Version/Revision:
Version/Revision date:
Protocol date:
6HS 2021
0135-0349
1.0
NA
x
Arrived or admitted to the hospital within 4.5 hours of symptom
onset
x
If treated with IV rt-PA: received IV rt-PA within 4.5 hours of
symptom onset
Exclusion criteria:
x
Documented IVT contraindication except age to IV rt-PA treatment
according to the SmPC.
x
Missing any one of the key data (age, gender, baseline National
Institutes of Health Stroke Scale [NIHSS], time of symptom onset,
time of hospital arrival or admission, IVT status, time of IV rt-PA
treatment)
x
Received thrombolysis agents other than rt-PA (urokinase,
tenecteplase, recombinant plasminogen activator, prourokinase,
streptokinase)
x
Received endovascular treatment
x
Received IV rt-PA after 4.5 hours of symptom onset
Eligible patients from the ZAQCC platform will be divided into 2 cohorts:
x
IV rt-PA cohort: AIS patients aged > 80 years who received IV rt-PA
within 4.5 hours of symptom onset
x
Non-reperfusion cohort: AIS patients aged > 80 years who arrived or
were admitted to the hospital and did not receive any reperfusion
treatments
Variables:
Primary outcome:
x
Favourable outcome (mRS 0-1) at 1 year
Secondary outcomes: 
x
Any intracranial haemorrhage (ICH) during hospitalisation
x
All-cause mortality during hospitalisation
x
Independence (mRS 0-2) at 1 year
x
Distribution of mRS score at 1 year
x
All-cause mortality at 1 year

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Name of company:
Boehringer Ingelheim
Name of finished medicinal 
product:  
Actilyse®
Name of active ingredient:
Alteplase
Study
number:
Version/Revision:
Version/Revision date:
Protocol date:
6HS 2021
0135-0349
1.0
NA
x
Baseline characteristics (age, gender, NIHSS, etc.)
Covariates:
x
Demographic and sociological characteristics
o
Age
o
Gender (male, female)
o
Body weight
o
Medical insurance status (urban employee basic medical
insurance, urban resident basic medical insurance, new rural
cooperative medical insurance, other insurance, no
insurance)
x
Lifestyle related characteristics
o
Smoking status (current smoker, former smoker, never
smoker)
x
Stroke severity (baseline NIHSS)
x
Time from symptom onset to hospital admission
x
For patients in the IV rt-PA cohort:
o
Time from symptom onset to treatment
o
Time from hospital admission to treatment
o
rt-PA dosage (dichotomised as standard dosage and low
dosage)
x
Comorbidities at baseline
o
Diabetes
o
Coronary artery disease
o
Atrial fibrillation
o
Prior stroke/transient ischaemic attack

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Name of company:
Boehringer Ingelheim
Name of finished medicinal 
product:  
Actilyse®
Name of active ingredient:
Alteplase
Study
number:
Version/Revision:
Version/Revision date:
Protocol date:
6HS 2021
0135-0349
1.0
NA
o
Hypertension
x
Co-medication at baseline (anti-platelet, oral anticoagulation, lipid
lowering)
x
Hospital level
o
Grade 2
o
Grade 3
x
Duration of hospitalization
x
Reasons for not being treated with rt-PA for rt-PA non treatment
group
Data sources:
ZSQCC platform
Study size:
Approximately 1301 or 1146 patients, calculated by 2:1 or 1:1 treatment 
ratio, respectively.
Data analysis:
To account for potential confounding, the study cohorts (patients who 
received IV rt-PA and patients who did not receive reperfusion treatment) 
will be matched by baseline characteristics using the propensity score 
matching (PSM) method. The PSM aims to balance the 2 treatment cohorts 
on baseline covariates. The feasibility of PSM will be evaluated based on 
available sample size and descriptive results. If patient characteristic 
between the 2 cohorts are significantly different, the study design will be re-
evaluated before proceeding to analysis. The Nearest Neighbour method of 
PSM will be used to select the matched samples. The final list of baseline 
characteristics in the PSM will be decided in conjunction with Boehringer 
Ingelheim. All the variables listed in the section covariates will be 
considered. Covariables including duration of hospitalization and reasons 
for untreated with rt-PA are only for descriptive analysis. The distribution of 
baseline characteristics will be presented before and after the matching 
process. Absolute standardized difference (ASD) between the compared 
groups will be calculated, in which a ı10% ASD will be considered a 
meaningful difference. 
For baseline covariates that are not sufficiently balanced after PSM, the 
covariates will be included in an appropriate multivariate model to adjust for
those differences.
Main Analysis:
A comparison of 1-year favourable outcome between the  propensity score 

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Name of company:
Boehringer Ingelheim
Name of finished medicinal 
product:  
Actilyse®
Name of active ingredient:
Alteplase
Protocol date:
Study
number:
Version/Revision:
Version/Revision date:
6HS 2021
0135-0349
1.0
NA
(PS)-matched cohorts will be calculated using a chi-square test. A logistic 
regression model will be used to calculate odds ratios between cohorts. 
For the secondary outcomes, descriptive summaries will be conducted in the 
PS-matched cohorts separately. For categorical variables including any ICH 
and mortality during hospitalisation, independence (mRS 0-2) at 1 year, the 
percentage and 95% confidence interval will be calculated. A logistic 
regression model will be used to calculate odds ratios.  
For time to death up to 1 year and time to ICH during hospitalisation, a
Kaplan-Meier curve will be used to analyse the data. Cox regression will be 
used to estimate hazard ratio for 1-year all-cause mortality between cohorts. 
For the distribution of mRS, an ordinal logistic regression model will be used 
to calculate the common odds ratio between the matched cohorts. 
For baseline characteristics of patients, the absolute standardised difference 
(ASD) between the PS-matched cohorts will be calculated, where an ASD of 
at least 10% ASD will be considered a meaningful difference.
Milestones:
Protocol Approval: Oct 2021
Start of data collection: NA
End of data collection: NA
Statistical and epidemiological analysis plan completion: Apr 2022 
Final report of study results: Jul 2022 

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5.
AMENDMENTS AND UPDATES
None. 

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6.
MILESTONES 
Milestone
Planned Date
Protocol Approval 
Oct 2021 
IRB/IEC approval 
Dec 2021 
Statistical and epidemiological analysis plan completion 
Apr 2022 
Final report of study results: 
Jul 2022 

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7.
RATIONALE AND BACKGROUND
Stroke is the leading cause of mortality and disability among adults in China, which is 
characterized by high morbidity, disability and mortality. With the aging of society, the 
acceleration of urbanization, and popular unhealthy lifestyle among residents, the stroke 
burden in China displayed an explosive growth trend and elderly patients with AIS are 
becoming common in China. [R19-3903], [R21-1796], [R21-04631] According to the 2018 data in 
Chinese acute ischaemic stroke (AIS) patients, it was deduced that there were 12.42 million 
Chinese AIS patients and 1.96 million patients died due to AIS.[R19-3903] In addition, according 
to the report of the Chinese Stroke Centre Alliance (CSCA) from 2015 to 2017, about one 
fourth of the AIS patients recorded in the CSCA platform were elderly patients 
aged > 75 years.[P21-04633] Therefore, the prevention and treatment of stroke is still facing huge 
challenges in China, and further strengthening the prevention and treatment system and 
improving the prognosis of stroke patients are urgent needs in stroke management. 
The benefit of intravenous thrombolysis (IVT) within 4.5 hours of symptom onset for AIS 
patients has been well proven and recommended by international/national 
guidelines.[P19-10385], [P21-02289], [P19-10855] A meta-analysis of randomised controlled trials 
(RCTs) demonstrated a positive benefit-risk ratio for alteplase when used according to label 
criteria.[P20-06029] The benefit–risk ratio changed with time to treatment: earlier treatment was 
associated with better outcomes, while delayed treatment was associated with reduced 
benefit.
When Actilyse® was first approved for the treatment of AIS, it was indicated only for patients 
aged 18 to 80 years. Recent studies suggested that patients aged > 80 years may also benefit 
from intravenous (IV) recombinant tissue plasminogen activator (rt-PA) when given within 
4.5 hours of symptom onset.[P14-16838] Data from both RCTs and observational studies showed 
consistent results: patients aged > 80 years who received IV rt-PA within 4.5 hours of 
symptom onset had improved outcomes without increasing haemorrhage rates, although this 
elderly patient population had a higher mortality rate and poorer functional outcomes than 
younger patients do. In addition, the international guidelines recommend the IV thrombolysis 
with alteplase within 3 hours and 3 to 4.5 hours of stroke onset in suitable AIS patients 
aged >80 years.[P19-10385]
All countries in the European Union including Germany, Austria, and Belgium have 
successively approved Actilyse® to remove the age restriction of 80 years since Jun 2018. 
Until now, there is limited data regarding the safety or effectiveness of IV rt-PA among 
Chinse AIS patients aged > 80 years. Therefore, in China the age restriction of 80 years has 
not been removed yet by National Medical Products Administration. However, Chinese 
Guidelines for Diagnosis and Treatment of AIS 2014[P21-04636] and 2018[P19-10855] removed the 
age restriction of 80 years in the recommendations for IV thrombolysis with alteplase within 
3 hours and 3 to 4.5 hours of stroke onset, respectively. In addition, it is common to give IV 
thrombolytic therapy to Chinese AIS patients aged > 80 years in clinical practice according to 
local guidelines.[P19-10855], [P21-04637]
In January 2020, the Chinese Centre for Drug Evaluation (CDE) released Guidelines for
Real-World Evidence to Support Drug Development and Review (Interim). In this guideline, 
China CDE listed several scenarios demonstrating how real-world evidence (RWE) can be 

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used to support drug development and regulatory decision making. One of the scenarios was
to use RWE to provide evidence for changing leaflets of approved drugs, including adding 
new applicable populations.  
We propose to use the Zhejiang Stroke Quality Control Centre (ZSQCC) platform data to 
conduct this retrospective study comparing the 1-year clinical outcome of IV rt-PA treated 
patients versus non-reperfusion elderly (> 80 years) AIS patients.

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8.
RESEARCH QUESTION AND OBJECTIVES
Research question: Can Chinese AIS patients older than 80 years benefit from IV rt-PA
treatment within 4.5 hours of symptom onset in a real-world clinical setting? 
Primary objective:
x
To compare the 1-year neurological favourable functional outcome (as measured by 
modified Rankin Scale [mRS] score, defined as mRS 0-1) of Chinese AIS patients 
aged > 80 years who received IV rt-PA treatment within 4.5 hours of symptom onset 
versus those who arrived or were admitted to the hospital within 4.5 hours of 
symptom onset and did not receive reperfusion therapy.
Secondary objectives:
x
To compare in-hospital and other 1-year clinical outcomes (including any intracranial 
haemorrhage (ICH), all-cause mortality during hospitalisation, independence (mRS 
0-2) at 1 year, distribution of mRS score at 1 year, and all-cause mortality at 1 year.
Detailed description of these outcomes are provided in the section “secondary 
outcomes”) of elderly AIS patients who received IV rt-PA treatment within 4.5 hours 
of symptom onset versus those who arrived or were admitted to the hospital within 
4.5 hours of symptom onset and did not receive any reperfusion therapy. 
x
To compare the baseline characteristics of AIS patients aged > 80 years treated with 
IV rt-PA within 4.5 hours of symptom onset versus AIS patients aged > 80 years 
who arrived or were admitted to the hospital within 4.5 hours of symptom onset and 
did not receive reperfusion treatment in the ZSQCC platform to evaluate potential 
channelling. 
.

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9.
RESEARCH METHODS
9.1
STUDY DESIGN
This is a NIS based on existing data. We will analyse data of AIS patients aged > 80 years in 
China collected from the ZSQCC platform.[P21-04780], [P21-04783], [P21-04784], [P21-04779], [P21-04782] In 
this study, the index date for the IV rt-PA cohort is defined as the date when rt-PA treatment 
is initiated. For the non-reperfusion cohort, index date is defined as the date when the patient 
arrived at the hospital. 
Approximately 1301 or 1146 AIS patients in total are planned to be included to this study, 
calculated by 2:1 or 1:1 treatment ratio, respectively.
Patients meeting the inclusion/exclusion criteria will be divided into 2 cohorts: 
x
IV rt-PA cohort: AIS patients aged > 80 years who received IV rt-PA within 
4.5 hours of symptom onset 
x
Non-reperfusion cohort: AIS patients aged > 80 years who arrived or admitted to the 
hospital within 4.5 hours of symptom onset and did not receive any reperfusion 
treatments
Propensity score matching (PSM) will be used to match the baseline characteristics between 
the above 2 cohorts. Clinical outcomes and baseline characteristics will be compared between 
the matched cohorts.
The flow of data selection for each of the 2 reporting patient cohorts is depicted in Figure 1
below. 
Figure 1 
Patient cohorts selected for the non-interventional study

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9.2
SETTING
9.2.1
Study sites
In this study, AIS patient data from 80 stroke centres in the ZSQCC platform from 
January 2017 to March 2020 will be used.
9.2.2
Study population
No sampling will be undertaken and all patients who meet all the inclusion criteria and none 
of the patients presenting with at least one exclusion criterion will be included.
The inclusion and exclusion criteria are listed below: 
Inclusion criteria:
x
Patients registered in the ZSQCC platform from Jan 2017 to Mar 2020 
x
> 80 years of age
x
Diagnosed with AIS at admission
x
Arrived or admitted to the hospital within 4.5 hours of symptom onset 
x
If treated with IV rt-PA: received IV rt-PA within 4.5 hours of symptom onset 
Exclusion criteria:
x
Documented IVT contraindication except age to IV rt-PA treatment according to the 
SmPC.  
x
Missing any one of the key data (age, gender, baseline National Institutes of Health 
Stroke Scale [NIHSS], time of symptom onset, time of hospital arrival or admission, 
IVT or not, time of IV rt-PA treatment)
x
Received thrombolysis agents other than rt-PA (urokinase, tenecteplase, recombinant 
plasminogen activator, prourokinase, streptokinase) 
x
Received endovascular treatment
x
Received IV rt-PA after 4.5 hours of symptom onset 
9.2.3
Study visits
Not applicable. 
9.2.4
Study discontinuation
Boehringer Ingelheim reserves the right to discontinue the study at any time for the following 
reason:
x
Violation of Good Pharmacoepidemiology Practice (GPP), the study protocol, or the 
contract by study site, investigator or research collaborator, disturbing the 
appropriate conduct of the study 

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9.3
VARIABLES
9.3.1
Exposures
The exposure of this study is IV rt-PA treatment within 4.5 hours of symptom onset.
9.3.2
Outcomes
9.3.2.1
Primary outcome 
x
Favourable outcome (mRS 0-1) at 1 year 
9.3.2.2
Secondary outcomes 
x
Any intracranial haemorrhage (ICH) during hospitalisation
x
All-cause mortality during hospitalisation
x
Independence (mRS 0-2) at 1 year
x
Distribution of mRS score at 1 year 
x
All-cause mortality at 1 year
x
Baseline characteristics (age, gender, NIHSS, etc.)
9.3.3
Covariates 
The covariates to be collected at baseline as follows: 
x
Demographic and sociological characteristics
o
Age
o
Gender (male, female) 
o
Body weight 
o
Medical insurance status (urban employee basic medical insurance, urban 
resident basic medical insurance, new rural cooperative medical insurance, 
other insurance, no insurance) 
x
Lifestyle related characteristics
o
Smoking status (current smoker, former smoker, never smoker) 
x
Stroke severity (baseline NIHSS)
x
Time from symptom onset to hospital admission
x
For patients in the IV rt-PA cohort: 
o
Time from symptom onset to treatment
o
Time from hospital admission to treatment
o
rt-PA dosage (dichotomised as standard dosage and low dosage) 
x
Comorbidities at baseline
o
Diabetes

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o
Coronary artery disease 
o
Atrial fibrillation
o
Prior stroke/transient ischaemic attack
o
Hypertension 
x
Co-medication at baseline 
o
Anti-platelet
o
Oral anticoagulation 
o
Lipid lowering 
x
Hospital level
o
Grade 2
o
Grade 3
Other covariates including: 
x
Duration of hospitalization
x
Reasons for not being treated with rt-PA for rt-PA non treatment group 
9.4
DATA SOURCES
9.4.1
ZSQCC platform
The current study will be conducted based on data from the ZSQCC platform, which is a 
continuous comprehensive reporting system that collects 100000 patient-level data from 80 
stroke centres from January 2017 to March 2020. 
All printed medical documents for consecutive AIS patients admitted in the stroke centre will 
be provided and scanned by investigators from ZSQCC. Only the de-identified scanned 
documents will be preserved as images in a safe information database. The local 
infrastructure and characteristics of each recruited centre will also be recorded.
The database includes patient demographic information, baseline clinical characteristics,
indicators related to diagnosis and treatment during hospitalisation and follow-up after 
discharge. The platform staffs tried to follow up all discharged patients by a phone call at 
1-year discharge. In addition, patients who received rt-PA treatments were followed up by a
phone call at 3-month after discharge. Telephone follow-up of the platform was conducted by 
platform staffs. The follow-up standards were unified, and telephone recordings were all 
kept. Neurologists conducted trainings at regular intervals for platform staffs and randomly 
checked the telephone recordings. Several studies based on this dataset were approved by the 
Second Affiliated Hospital of Zhejiang University Institutional Review Board (IRB) and 
were published in peer-reviewed journals.[P21-04780], [P21-04783], [P21-04784], [P21-04779], [P21-04782]
9.4.2
CSCA platform
The CSCA is a national, hospital-based, multicentre, voluntary, multifaceted intervention and 
continuous quality improvement initiative, launched by Chinese Stroke Association in 2015. 
This programme is made available to all Chinese grade 2 and 3 hospitals. Hospitals continued 
to join the programme in a staggered manner. By Jul 2019, 1476 hospitals (720 grade 2 
hospitals, 756 grade 3 hospitals) had participated into this programme. Hospital 
characteristics, including geographic region, teaching status, hospital volume (grade 2 and 3) 
and annual stroke volume, are surveyed. Data were collected via the web-based patient data 

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collection and management tool (
), 
abstracted via chart review, coded, de-identified and transmitted in a secure manner to 
maintain patient confidentiality compliant with national privacy standards. The following 
data were collected for each hospitalization: patient demographics, history of disease and 
medication, hospital presentation, initial neurological status, medications and interventions, 
reperfusion strategy and in-hospital outcomes and complications.
9.5
STUDY SIZE
A feasibility assessment was conducted in June 2020. The results showed that there were 
approximately 1561 elderly AIS patients who were treated with IV rt-PA and 1037 patients 
who were admitted to the hospital within 4.5 hours of symptom onset without IVT 
contraindication and did not receive reperfusion treatment from Jan 2017 to Mar 2020 
according to the ZSQCC platform database.
A meta-analysis of RCTs showed that the 3-month favourable outcome (mRS 0-1) with IV
rt-PA versus the placebo arm in patients above 80 years of age was 19.1% versus 13.1% 
(relative risk [RR]: 1.46). In safe implementation of thrombolysis in upper time window 
monitoring study, the 3-month favourable outcome for IV rt-PA treated elderly patients was 
26.6%. In this study, we assume the 1-year favourable outcome for IV rt-PA treated elderly 
patients is 28%, with the same RR (1.46) observed in RCTs, and the 1-year favourable 
outcome for non-reperfusion cohort is 19.2%. With the treatment ratio 2:1 between the IV 
rt-PA cohort and the non-reperfusion cohort, 1106 patients in total are needed to detect the 
treatment difference of 8.8% with 90% power and a 2-sided alpha of 0.05. Considering a 15% 
rate of loss to visit, 1301 patients in total are needed.  If a 2:1 match cannot reach  good 
match in terms of the major potential confounders, we may conduct a 1:1 match instead. 
Considering a treatment ratio 1:1 with the same assumption described above with power of 
90% at a 2-sided, 974 patients are needed to detect 8.8% treatment difference, considering 
15% loss to visit, 1146 patients are needed in total.
9.6
DATA MANAGEMENT
The data will be managed by ZSQCC. The source codes for data management and data 
analyses will be kept for inspection for at least 5 years after publication of the results. 
Full details of the data management plan are documented in a separate NIS-Data 
Management and Review Plan (NIS-DMRP).
9.7
DATA ANALYSIS
For the purpose of this study, analyses will generally be descriptive in nature and will be 
conducted using SAS statistical software (version 9.3 or higher). Descriptive data regarding 
patient demographic and clinical characteristics will be calculated. For categorical measures, 
data will include the frequency (number of cases [n]) and percentage (%) of total study 
patients observed in each category (N). All variables will be summarised descriptively by 
tabular displays of mean, median, ranges, and standard deviations of continuous variables and 
frequency distributions of categorical variables. When necessary, continuous variables also 

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will be categorised into intervals, with the distribution of patients (n, N, %) for each interval 
provided. 
The statistical analysis plan for the study is summarised below. Full details of the statistical 
analysis will be documented in the statistical and epidemiological analysis plan, which will 
be finalised before the end of data extraction. 
As this is a NIS based on existing data, no formal hypothesis testing or comparisons between 
treatment cohorts are planned.
9.7.1
Main analysis 
To account for potential confounding, the study cohorts (patients who received IV rt-PA and 
patients who did not receive reperfusion treatment) will be 1:1 or 1:2 matched by baseline 
characteristics using the PSM method. The PSM aims to balance the 2 treatment cohorts on 
baseline covariables. The feasibility of PSM will be evaluated based on available sample size 
and descriptive results. If patient characteristic between the 2 cohorts are significantly 
different, i.e., less than 50% of patients in the IV rt-PA cohort can be matched to the 
non-reperfusion cohort based on PSM, the study design will be re-evaluated before 
proceeding to analysis. The Nearest Neighbour method of PSM will be used to select the 
matched samples. The final list of baseline characteristics in the PSM will be decided in 
conjunction with BI. All variables listed in the covariates will be considered. Covariables 
including duration of hospitalization and reasons for untreated with rt-PA are only for 
descriptive analysis. The distribution of baseline characteristics will be presented before and
after the matching process. Absolute standardized difference (ASD) between the compared groups 
will be calculated, in which a ı10% ASD will be considered a meaningful difference. For baseline 
covariates that are not sufficiently balanced after PSM which is assessed using ASD, the 
covariates will be included in an appropriate multivariate model to adjust for those 
differences.
For the primary outcome, a comparison of 1-year mRS 0-1 score between the 2 propensity 
score (PS)-matched cohorts will be calculated using a chi-square test. A logistic regression 
model will be used to calculate odds ratios between 2 matched cohorts. 
For the secondary outcomes, descriptive summaries will be conducted in the PS-matched 
cohorts separately. For categorical variables including any ICH during hospitalisation, 
mortality during hospitalisation, and mRS 0-2 at 1 year, the percentage and 95% confidence 
interval will be calculated. A logistic regression model will be used to calculate the odds 
ratios.
For time to death up to 1 year and time to ICH during hospitalisation, a Kaplan-Meier curve 
will be used to analyse the data. Cox regression will be used to estimate hazard ratio for 
1-year all-cause mortality between PS-matched cohorts. 
For the distribution of mRS, an ordinal logistic regression model will be used to calculate the 
odds ratio between the PS-matched cohorts. 

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9.7.3
Safety analysis 
This is a NIS based on existing data. From safety information collecting and reporting 
perspective, this study will not involve individual medical record review, thus no adverse 
event/adverse drug reaction information is required to collect. The analysis refers to 
Section 9.7.2.
9.8
QUALITY CONTROL
The study will strictly follow BI standard operation procedures (SOPs). In addition, this study 
will follow key elements of the Guideline for GPP. The statistical analytic approach will be 
reviewed/repeated by a second analyst. The study report will be reviewed, approved and 
archived per BI SOP.
All the data cleaning, integration, and analysis will be conducted under the guidance and 
supervision of ZSQCC.
Greater details are documented in the NIS-DMRP.
9.9
LIMITATIONS OF THE RESEARCH METHODS
This is a NIS based on existing data. Although PSM is used, we cannot rule out the influence 
of unmeasured confounding factors. In this study, potential limitations of the study design 
can be listed as:
x
Zhejiang is an economically advanced province in China. Patients in this study may
not be fully representative to all AIS patients in China. We plan to compare the 

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baseline characteristics of patients in this study with those from CSCA to evaluate 
the representativeness of the population in this study. 
x
AIS patient data from the ZSQCC platform were reported by the stroke centre 
without external monitoring. 
x
The treatment adapted for AIS patients may be different among stroke centres.
x
The completeness of the captured data and potential for misclassification of data 
could differ among stroke centres. 
x
Some important variables may not be collected in the database. For example, 
patients’ education level was not available in the database. Another example is that 
patients who did not receive rt-PA treatments were not followed up at 3 months after 
discharge. Therefore, for outcomes at 3 months we could only describe them in the 
rt-PA treated cohort. 
9.10
OTHER ASPECTS
9.10.1
Data quality assurance 
A quality assurance audit/inspection of this study may be conducted by the investigator or by 
IRBs / Independent Ethics Committee (IECs) or by regulatory authorities. The quality 
assurance auditor will have access to the investigator’s study-related files and correspondence 
of this study. 
9.10.2
Study records
9.10.2.1
Source documents 
Source documents provide evidence for the existence of the patient and substantiate the 
integrity of the data extracted. 
9.10.2.2
Direct access to source data and documents
The investigator/institution will permit study-related audits, IRB/IEC review and regulatory 
inspection, providing direct access to all related database/documents. All source documents, 
including progress notes must be available at all times for review by the inspection by health 
authorities.  

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10.
PROTECTION OF HUMAN SUBJECTS
The study will be carried out in compliance with the protocol, the principles laid down in the 
Declaration of Helsinki, in accordance with the International Conference on Harmonisation 
Harmonised Tripartite Guideline for Good Clinical Practice (to the extent applicable to the 
NIS setting and required by local regulations), Good Epidemiological Practice, guidelines for 
GPP, and the relevant BI SOPs. 
10.1
STUDY APPROVAL AND PATIENT INFORMATION
This NIS will be initiated only after all required legal documentation has been reviewed and 
approved by the respective IRB/IEC and Competent Authority according to national and 
international regulations. The same applies for the implementation of changes introduced by 
amendments.
10.2
STATEMENT OF CONFIDENTIALITY
Individual patient medical information obtained as a result of this study is considered 
confidential and disclosure to third parties is prohibited with the exceptions noted below. 
Patient confidentiality will be ensured by using patient identification code numbers. 
Data generated as a result of the study need to be available for inspection upon request by the 
participating physicians, the sponsor’s representatives, by the IRB/IEC and the regulatory 
authorities.

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11.
MANAGEMENT AND REPORTING OF ADVERSE 
EVENTS/ADVERSE REACTIONS
Based on current guidelines from the International Society for 
Pharmacoepidemiology[R11-4318] and the European Medicines Agency[R13-1970], NIS such as the 
one described in this proposal, conducted using health care records, do not require expedited 
reporting of suspected adverse events/reactions. Specifically, as stated in section VI.C.1.2.1 
of Guideline on Good Pharmacovigilance Practices, Module VI – Management and Reporting 
of Adverse Reactions to Medicinal Products, for NIS designs, which are based on use of 
secondary data, reporting of adverse reactions is not required. Not applicable based on the 
secondary use of data without any potential that any employee of BI or agent working on 
behalf of BI will asceses individually identifiable patient data. 

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12.
PLANS FOR DISSEMINATING AND COMMUNICATING 
STUDY RESULTS
The rights of the investigator and of the sponsor with regard to publication of the results of 
this study are described in the investigator contract. As a general rule, no study results should 
be published prior to finalisation of the study report. 
Boehringer Ingelheim intends to use data from this study to prepare peer-reviewed 
publications and other scientific communications such as abstracts, posters, and podiums 
presentations. 

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13.
REFERENCES
13.1
PUBLISHED REFERENCES
R19-3903 
Wang LD, Liu JM, Yang Y, Peng B, Wang YL, and others on behalf of the 
compiling group of the Report on Stroke Prevention and Treatment in China 
2018. The Prevention and Treatment of Stroke Still Face Huge 
Challenges—Brief Report on Stroke Prevention and Treatment in China 
2018. Chin Circ J. 2019; 34(2):105–119. 
R21-1796 
Gao Y, Jiang B, Sun H, Ru X, Sun D, Wang L, Wang L, Jiang Y, Feigin 
VL, Wang Y, Wang W. The burden of stroke in China: Results from a 
nationwide population-based epidemiological survey. PLoS One. 2018; 
13(12):e0208398. 
P21-04631 
Wang YJ, Li ZX, Gu HQ, Zhai Y, Jiang Y, Zhao XQ, Wang YL, Yang X, 
Wang CJ, Meng X, Li H, Liu LP, Jing J, Wu J, Xu AD, Dong Q, Wang D, 
Zhao JZ; China Stroke Statistics 2019 Writing Committee. China Stroke 
Statistics 2019: A Report From the National Center for Healthcare Quality 
Management in Neurological Diseases, China National Clinical Research 
Center for Neurological Diseases, the Chinese Stroke Association, National 
Center for Chronic and Non-communicable Disease Control and Prevention, 
Chinese Center for Disease Control and Prevention and Institute for Global 
Neuroscience and Stroke Collaborations. Stroke Vasc Neurol. 2020; 
5(3):211-239. 
P21-04633 
Wang YJ, Li ZX, Wang YL, Zhao XQ, Liu LP, Yang X, Wang CY, Gu HQ,
Zhang FY, Wang CJ, Xian Y, Wang DZ, Dong Q, Xu AD, Zhao JZ, on 
behalf of Chinese Stroke Center Alliance investigators. Chinese Stroke 
Center Alliance: a national effort to improve healthcare quality for acute 
stroke and transient ischaemic attack: rationale, design and preliminary 
findings. Stroke Vasc Neurol. 2018; 3:256-262. 
P19-10385 
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, 
Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, 
Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, 
Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early 
Management of Patients With Acute Ischemic Stroke: 2019 Update to the 
2018 Guidelines for the Early Management of Acute Ischemic Stroke: A 
Guideline for Healthcare Professionals From the American Heart 
Association/American Stroke Association. Stroke. 2019; 50(12):e344-e418. 
P21-02289 
Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, 
Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European 
Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute 
ischaemic stroke. Eur Stroke J. 2021; 6(1):I-LXII.
P19-10855 
Society of Neurology, Chinese Stroke Society. Chinese guidelines for 
diagnosis and treatment of acute ischemic stroke 2018. Chin J Neurol. 2018; 
51(9):666-682. 

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P20-06029 
Bluhmki E, Danays T, Biegert G, Hacke W, Lees KR. Alteplase for Acute 
Ischemic Stroke in Patients Aged >80 Years: Pooled Analyses of Individual 
Patient Data. Stroke. 2020; 51(8):2322-2331. 
P14-16838 
Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, Brott T, 
Cohen G, Davis S, Donnan G, Grotta J, Howard G, Kaste M, Koga M, von 
Kummer R, Lansberg M, Lindley RI, Murray G, Olivot JM, Parsons M, 
Tilley B, Toni D, Toyoda K, Wahlgren N, Wardlaw J, Whiteley W, del 
Zoppo GJ, Baigent C, Sandercock P, Hacke W; Stroke Thrombolysis 
Trialists' Collaborative Group. Effect of treatment delay, age, and stroke 
severity on the effects of intravenous thrombolysis with alteplase for acute 
ischaemic stroke: a meta-analysis of individual patient data from 
randomised trials. Lancet. 2014; 384(9958):1929-1935. 
P21-04636 
Society of Neurology, Chinese Stroke Society. Chinese guidelines for 
diagnosis and treatment of acute ischemic stroke 2014. Clin J Neurol. 2015;
48(4):246-257. 
P21-04637 
Liu LP, Chen WQ, Duan WY, Huo XC, Xu WH, Li SJ, Li ZX, Huang LA, 
Wang CX, Zheng GH, Wang YJ. Chinese Stroke Association Guidelines for 
Clinical Management of Cerebrovascular Disorders (Excerpts)-Clinical 
Management of Ischemic Cerebrovascular Disorders. Chin J Stroke. 2019; 
14(7):709-726. 
P21-04780 
Zhang CC, Lou M, Chen ZC, Chen HF, Xu DJ, Wang ZM, Hu HF, Wu CL, 
Zhang XL, Ma XD, Wang YX, Hu HT. Analysis of intravenous 
thrombolysis time and prognosis in patients with in-hospital stroke. J
Zhejiang Univ (Med Sci). 2019; 48(3):260-266. 
P21-04783 
Chen HF, Gong XX, Xu DJ, Wang ZM, Hu HF, Wu CL, Zhang XL, Ma 
XD, Wang YX, Hu HT, Lou M, Chen ZC. Advanced treatment time 
improves outcomes of patients with ischemic stroke undergoing reperfusion 
therapy. J Zhejiang Univ (Med Sci). 2019; 48(3):247-253. 
P21-04784 
Zhong WS, Chen ZC, Chen HF, Xu DJ, Wang ZM, Hu HF, Wu CL, Zhang 
XL, Ma XD, Wang YX, Hu HT, Lou M. Effects of emergency medical 
service on prognosis of ischemic stroke patients treated with intravenous 
thrombolysis. J Zhejiang Univ (Med Sci). 2019; 48(3):241-246. 
P21-04779 
Pan FH, Lou M, Chen ZC, Chen HF, Xu DJ, Wang ZM, Hu HF, Wu CL, 
Zhang XL, Ma XD, Wang YX, Hu HT. Effect of different working time on 
the prognosis of ischemic stroke patients undergoing intravenous 
thrombolysis. J Zhejiang Univ (Med Sci). 2019; 48(3):267-274. 
P21-04782 
Tao AY, Wang ZM, Chen HF, Xu DJ, Hu HF, Wu CL, Zhang XL, Ma XD, 
Wang YX, Hu HT, Lou M. Association of atrial fibrillation with 
hemorrhagic transformation after intravenous thrombolysis in patients with 
ischemic stroke. J Zhejiang Univ (Med Sci). 2019; 48(3):254-259. 
R11-4318 
Guidelines for Good Pharmacoepidemiology Practices (GPP) (revision 2: 
April 2007). Source: 
http://www.pharmacoepi.org/resources/guidelines_08027.cfm (access date: 

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13 September 2011); Bethesda: International Society for 
Pharmacoepidemiology (ISPE); 2007. [B(MB1]
R13-1970 
European Medicines Agency (EMA), Heads of Medicines Agencies 
(HMA); 2012.Guideline on good pharmacovigilance practices (GVP): 
module VI - management and reporting of adverse reactions to medicinal 
products (22 June 2012, EMA/873138/2011). 
13.2
UNPUBLISHED REFERENCES
None. 

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ANNEX 1. LIST OF STAND-ALONE DOCUMENTS
None. 

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ANNEX 2. ENCEPP CHECKLIST FOR STUDY PROTOCOLS
1.
Study title: Effectiveness and safety of IV rt-PA treatment in Chinese AIS patients 
aged above 80 years: a real-world study
2.
EU PAS Register® number: 
3.
Study reference number (if applicable):
4.
Section 1: Milestones
Yes
No
N/A
Section 
Number
1.1
Does the protocol specify timelines for 
1.1.1 Start of data collection1
6
1.1.2 End of data collection2
6
1.1.3 Progress report(s)
NA
1.1.4 Interim report(s)
NA
1.1.5 Registration in the EU PAS Register®
NA
1.1.6 Final report of study results.
6
Comments:
5.
Section 2: Research question
Yes
No
N/A
Section 
Number
2.1
Does the formulation of the research question and 
objectives clearly explain: 
7 and 8 
2.1.1 Why the study is conducted? (e.g. to address an 
important public health concern, a risk identified in the 
risk management plan, an emerging safety issue)
7
2.1.2 The objective(s) of the study?
8
2.1.3 The target population? (i.e. population or subgroup to 
whom the study results are intended to be generalised)
9.2.2
2.1.4 Which hypothesis(-es) is (are) to be tested?
NA
2.1.5 If applicable, that there is no a priori hypothesis?
NA
Comments:
1 Date from which information on the first study is first recorded in the study dataset or, in the case of secondary use of data, the date from 
which data extraction starts.
2 Date from which the analytical dataset is completely available.

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6.
Section 3: Study design
Yes
No
N/A
Section 
Number
3.1
Is the study design described? (e.g. cohort, case-
control, cross-sectional, other design) 
9.1
3.2
Does the protocol specify whether the study is based 
on primary, secondary or combined data collection?
9.1 and 
9.3.2
3.3
Does the protocol specify measures of occurrence? 
(e.g., rate, risk, prevalence)
NA
3.4
Does the protocol specify measure(s) of association? 
(e.g. risk, odds ratio, excess risk, rate ratio, hazard 
ratio, risk/rate difference, number needed to harm 
(NNH))
NA
3.5
Does the protocol describe the approach for the 
collection and reporting of adverse events/adverse 
reactions? (e.g. adverse events that will not be 
collected in case of primary data collection)
9.7.3 and 
11
Comments:
7.
Section 4: Source and study populations
Yes
No
N/A
Section 
Number
4.1
Is the source population described?
9
4.2
Is the planned study population defined in terms of:
4.2.1 Study time period
6
4.2.2 Age and sex
9.2.2
4.2.3 Country of origin
9.2.2
4.2.4 Disease/indication
9.2.2
4.2.5 Duration of follow-up
9.4.1
4.3
Does the protocol define how the study population will 
be sampled from the source population? (e.g. event or 
inclusion/exclusion criteria)
9.2.2
Comments:
8.
Section 5: Exposure definition and 
measurement
Yes
No
N/A
Section 
Number
5.1
Does the protocol describe how the study exposure is 
defined and measured? (e.g. operational details for 
defining and categorising exposure, measurement of 
dose and duration of drug exposure)
9.3.1

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8.
Section 5: Exposure definition and 
measurement
Yes
No
N/A
Section 
Number
5.2
Does the protocol address the validity of the exposure 
measurement? (e.g. precision, accuracy, use of 
validation sub-study)
NA
5.3
Is exposure categorised according to time windows? 
NA
5.4
Is intensity of exposure addressed? (e.g. dose, 
duration)
9.3.3
5.5
Is exposure categorised based on biological mechanism 
of action and taking into account the pharmacokinetics 
and pharmacodynamics of the drug?
NA
5.6
Is (are) (an) appropriate comparator(s) identified?
NA
Comments:
9.
Section 6: Outcome definition and 
measurement
Yes
No
N/A
Section 
Number
6.1
Does the protocol specify the primary and secondary 
(if applicable) outcome(s) to be investigated?
9.3.2
6.2
Does the protocol describe how the outcomes are 
defined and measured? 
9.3.2
6.3
Does the protocol address the validity of outcome 
measurement? (e.g. precision, accuracy, sensitivity, 
specificity, positive predictive value, use of validation 
sub-study)
NA
6.4
Does the protocol describe specific outcomes relevant 
for Health Technology Assessment? (e.g. HRQoL, 
QALYs, DALYS, health care services utilisation, 
burden of disease or treatment, compliance, disease 
management)
NA
Comments:
10.
Section 7: Bias
Yes
No
N/A
Section 
Number
7.1
Does the protocol address ways to measure 
confounding? (e.g. confounding by indication)
9.7.1
7.2
Does the protocol address selection bias? (e.g. healthy 
user/adherer bias)
9.2.1, 9.7, 
and 9.9
7.3
Does the protocol address information bias? 
(e.g. misclassification of exposure and outcomes, time-
related bias)
9.7

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Comments:
11.
Section 8: Effect measure modification
Yes
No
N/A
Section 
Number
8.1
Does the protocol address effect modifiers? 
(e.g. collection of data on known effect modifiers, 
subgroup analyses, anticipated direction of effect)
NA
Comments:
12.
Section 9: Data sources
Yes
No
N/A
Section 
Number
9.1
Does the protocol describe the data source(s) used in 
the study for the ascertainment of:
9.1.1 Exposure? (e.g. pharmacy dispensing, general practice 
prescribing, claims data, self-report, face-to-face 
interview)
9.3.1 and 
9.4.1
9.1.2 Outcomes? (e.g. clinical records, laboratory markers or 
values, claims data, self-report, patient interview 
including scales and questionnaires, vital statistics)
9.3.2
9.1.3 Covariates and other characteristics?
9.3.3
9.2
Does the protocol describe the information available 
from the data source(s) on:
9.2.1 Exposure? (e.g. date of dispensing, drug quantity, dose, 
number of days of supply prescription, daily dosage,  
prescriber)
9.3.1
9.2.2 Outcomes? (e.g. date of occurrence, multiple event, 
severity measures related to event)
9.3.2
9.2.3 Covariates and other characteristics? (e.g. age, sex, 
clinical and drug use history, co-morbidity, co-
medications, lifestyle)
9.3.3
9.3
Is a coding system described for: 
9.3.1 Exposure? (e.g. WHO Drug Dictionary, Anatomical 
Therapeutic Chemical (ATC) Classification System)
NA
9.3.2 Outcomes? (e.g. International Classification of 
Diseases (ICD), Medical Dictionary for Regulatory 
Activities (MedDRA))
NA
9.3.3 Covariates and other characteristics?
NA
9.4
Is a linkage method between data sources described? 
(e.g. based on a unique identifier or other) 
NA
Comments: 

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13.
Section 10: Analysis plan
Yes
No
N/A
Section 
Number
10.1 Are the statistical methods and the reason for their 
choice described? 
9.7
10.2 Is study size and/or statistical precision estimated?
9.5
10.3 Are descriptive analyses included?
9.7
10.4 Are stratified analyses included?
NA
10.5 Does the plan describe methods for analytic control of 
confounding?
9.7.1
10.6 Does the plan describe methods for analytic control of 
outcome misclassification?
NA
10.7 Does the plan describe methods for handling missing 
data?
NA
10.8 Are relevant sensitivity analyses described?
9.7.2
Comments:
14.
Section 11: Data management and quality 
control
Yes
No
N/A
Section 
Number
11.1 Does the protocol provide information on data storage? 
(e.g. software and IT environment, database 
maintenance and anti-fraud protection, archiving)
9.8
11.2 Are methods of quality assurance described?
9.10.1
11.3 Is there a system in place for independent review of 
study results? 
NA
Comments:
15.
Section 12: Limitations
Yes
No
N/A
Section 
Number
12.1 Does the protocol discuss the impact on the study 
results of:
12.1.1 Selection bias?
9.9
12.1.2 Information bias?
9.9
12.1.3 Residual/unmeasured confounding? (e.g. anticipated 
direction and magnitude of such biases, validation sub-
study, use of validation and external data, analytical 
methods).
NA

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15.
Section 12: Limitations
Yes
No
N/A
Section 
Number
12.2 Does the protocol discuss study feasibility? (e.g. study 
size, anticipated exposure uptake, duration of follow-
up in a cohort study, patient recruitment, precision of 
the estimates)
9.1 and 9.2 
Comments:
16.
Section 13: Ethical/data protection issues
Yes
No
N/A
Section 
Number
13.1 Have requirements of Ethics Committee/ Institutional 
Review Board been described?
10
13.2 Has any outcome of an ethical review procedure been 
addressed?
10
13.3 Have data protection requirements been described?
10
Comments:
17.
Section 14: Amendments and deviations
Yes
No
N/A
Section 
Number
14.1 Does the protocol include a section to document 
amendments and deviations?
5
Comments:
18.
Section 15: Plans for communication of 
study results
Yes
No
N/A
Section 
Number
15.1 Are plans described for communicating study results 
(e.g. to regulatory authorities)? 
12
15.2 Are plans described for disseminating study results 
externally, including publication?
12
Comments:

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ANNEX 3. ADDITIONAL INFORMATION
None. 

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ANNEX 4. REVIEWERS AND APPROVAL SIGNATURES
The NIS Protocol must be sent for review to the following individuals prior to approval.
Reviewer
NIS involving BI 
product(s)
NIS not involving BI product(s)
Global NIS
Local NIS
NIS Lead
X 
X 
X 
Global TM Epi
X 
X 
X
Global TMM / TMMA / TM Market 
Access
X 
X 
Global Project Statistician
X 
X 
Global TM RA
Global PVWG Chair
X 
GPV SC
Global CTIS representative
Local Medical Director /Market 
Access
X (if local study)
X 
Local Head MAcc / HEOR Director
Global TA Head Epi*
Global TA Head Clinical 
Development / Medical Affairs / 
Market Access*
Global TA Head PV RM*
RWE CoE
(for NISnd only) 
X 
X 
X 
PSTAT / PSTAT-MA                   
(for NISnd only) 
X 
X 
X 
NIS DM
Local Head MA/Clinical 
Development
* After review by Global TM for function

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Study Title: Effectiveness and safety of IV rt-PA treatment in Chinese AIS patients 
aged above 80 years: a real-world study
Study Number: 0135-0349 
Protocol Version: 1.0 
I herewith certify that I agree to the content of the study protocol and to all documents 
referenced in the study protocol.
Position: ________ 
Name/Date: _______________________
Signature: _______________ 
Position: ________
Name/Date: _______________________
Signature: _______________
Position: ________
Name/Date: _______________________
Signature: _______________
Position: ________
Name/Date: _______________________
Signature: _______________
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Signature: _______________
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Name/Date: _______________________
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Name/Date: _______________________
Signature: _______________