Pilot Study of Pre-Ischemic Conditioning for Intracranial Atherosclerosis
Phase: NA
Conditions: Intracranial Atherosclerosis
Sponsor: Medical University of South Carolina

 
 
 
 
            
 
February 6, 2017 
                                                                             page 1 of 17 
 
Pilot Study of Pre-Ischemic Conditioning for Intracranial Atherosclerosis 
 
 
Study Protocol 
 
 
 
 
 
 Principal Investigators 
 
Marc I. Chimowitz MBChB 
Professor of Neurology 
Medical University of South Carolina 
 
David C Hess M.D 
Chairman and Professor of Neurology 
Medical College of Georgia 
Augusta University 
 
 
Funding for this Pilot Clinical Trial is through a Pilot Grant from the South Carolina Clinical & 
Translational Research (SCTR) Institute at the Medical University of South Carolina. SCTR is funded 
through a UL1 grant from NIH / NCATS.    
 
 
Version: February 6, 2017

 
 
2
TABLE OF CONTENTS 
1. Study Rationale ………………………………………………………………………….. 
3 
2. Primary Aims and Long-Term Goal ………………………………………………….. 
3 
3. Overview of Study Design ……………………………………………………………... 
4 
4.  
 
Subject Selection Criteria ……………………………………………………………… 
Inclusion Criteria 
Exclusion Criteria 
4 
5 
5 
 
5. Screening, Informed Consent, Randomization and Enrollment of Subjects 
6 
  6. RLIC Device And Ischemic Conditioning Regimen……………………………… 
6 
  7. Aggressive Medical Management …………………………………………………. 
7 
  8. Blood Biomarker Measurements…………………………………………………… 
7 
  9. MRI Measurements Of CBF And Other Perfusion Parameters………………… 
8 
10. Assessment Of Feasibility, Tolerability And Adherence To RLIC……………. 
8 
11. Randomization, Blinding, And Data Management………………………………. 
8 
12. Statistical Analyses…………………………………………………………………… 
8 
13. Protection Of Human Subjects……………………………………………………… 
8 
 
Bibliography……………………………………………………………………………. 
12 
 
Appendix 1. Adverse Event Questionnaire……………………………………….. 
15 
 
Appendix 2. Subject Diary……………………………………………………………. 
16 
 
 
 

 
 
3
 
1. 
STUDY RATIONALE 
Intracranial atherosclerotic arterial stenosis (ICAS) is an important cause of stroke in the US, and is especially 
prevalent in blacks, Asians, and Hispanics.1-6 Over the past 20 years, Dr. Chimowitz, one of the Co-PIs of this 
pilot study has led consecutive NIH funded multicenter clinical trials to test therapies for preventing stroke in 
subjects with ICAS:  The WASID trial showed that aspirin was as effective as warfarin for preventing stroke,  
and the SAMMPRIS trial showed that aggressive medical management (AMM) consisting of dual antiplatelet 
therapy and intensive risk factor management was more effective than percutaneous transluminal stenting for 
preventing stroke in recently symptomatic subjects with ICAS.7-9 However, among high-risk subjects (those 
with severe [70-99%] stenosis who presented with a stroke [rather than a TIA]), the 1-yr rate of recurrent stroke 
was 20.7% despite aggressive medical management. 10 Therefore, more effective therapies to prevent stroke 
in these high-risk patients remains an urgent need.  
One promising novel treatment is remote limb ischemic conditioning (RLIC), which involves producing 
repetitive, transient, non-injurious ischemia of a limb by inflating a blood pressure cuff proximally with the 
intention of protecting a distal organ (in this case, the brain) from subsequent ischemia.11 One of the co-
investigators in our group (Dr. David Hess at the Medical College of Georgia (MCG)) has conducted pre-
clinical studies using a bilateral carotid artery stenosis mouse model that showed RLIC increases cerebral 
blood flow (CBF), most likely by releasing nitrite into the circulation, and acts as a powerful neuroprotectant 
and vasculoprotectant.12-15  Additionally, two pilot randomized clinical trials performed in China showed that 
symptomatic subjects with ICAS treated with bilateral upper extremity RLIC daily for 180 or 300 days and 
medical management had a 70-75% lower rate of stroke compared with subjects treated with medical 
management alone.16,17 Although these preclinical studies and the two small Chinese pilot studies might 
suggest that the next step is to perform a multicenter randomized Phase II trial to determine the potential 
efficacy of RLIC in high-risk subjects with ICAS in the US, the lack of reliable data on how RLIC works in 
humans mandates an initial earlier phase trial to study potential mechanisms of action of RLIC in subjects with 
ICAS.   
 
2.   
PRIMARY AIMS AND LONG-TERM GOAL 
As a first step to collect preliminary data on the potential mechanisms of action of RLIC in humans, we will 
perform a small multicenter randomized pilot clinical trial of 10 subjects with ICAS at 4 participating sites 
(MUSC, MCG, UCLA and the University of Southern California (USC)) to accomplish the following primary 
aims:  
(1) Estimate the variability in CBF (measured by arterial spin labeling and perfusion MRI) and levels of putative 
biomarkers of the conditioning response (vasodilatory, inflammatory, fibrinolytic, microRNA) in the two 
treatment groups at enrollment and after 30 days of treatment. 
(2) Compare the changes in CBF and putative blood biomarkers of the conditioning response from enrollment 
to 30 days between the two treatment groups.  
(3) Obtain preliminary feasibility, tolerability and adherence data on the use of a RLIC device for 
secondary stroke prevention in subjects with ICAS.  
This study will provide preliminary data to enable planning of a subsequent grant submission to NIH to perform 
a Phase I / II trial with the following goals: to provide more rigorous data on the mechanisms of action of RLIC, 
and to determine the potential efficacy of RLIC for preventing stroke in high-risk subjects with ICAS. Our 
ultimate goal is to perform a large randomized multicenter NIH-funded Phase III trial to determine the efficacy 
of RLIC for preventing stroke.  

 
 
4
3. 
OVERVIEW OF STUDY DESIGN  
The design of the study is illustrated in Figure 1 below. In this prospective randomized pilot study, 10 eligible 
high-risk subjects with ICAS will be randomized to RLIC (bilateral upper extremity (BUE) daily for 30 days) plus 
AMM (n=5) or AMM alone (n=5). The AMM, which will be started at study enrollment and continued until close-
out in all subjects, will consist of aspirin 325 mg per day, clopidogrel 75 mg per day, and risk factor 
management primarily targeting a systolic BP < 140 mmHg and LDL cholesterol < 70 mg /dl. All subjects will 
undergo baseline brain arterial spin labeling (ASL) and perfusion MRI to measure CBF and have blood drawn 
for biomarkers 3-5 days after randomization to allow for washout of any effect from the test RLIC treatment that 
will be done prior to randomization to determine the subjects’ tolerability to RLIC treatment (see section 5 for 
more details on screening test). The period of 3-5 days will provide flexibility for scheduling these tests. After 
the baseline MRI and biomarker tests are completed, the subjects randomized to RLIC will begin daily RLIC for 
30 days. Each daily BUE RLIC treatment will consist of 4 cycles of 5-minute inflations of both blood pressure 
cuffs simultaneously to a pressure of 200 mm Hg with 5 minutes of reperfusion between each inflation using 
the Doctormate device (see Figure 2). All subjects will return for their close-out visits 33-35 days after enrolling 
in the study and will undergo brain ASL and perfusion MRI and have blood drawn for biomarkers at that visit. 
The study will be conducted at 4 sites (MUSC, MCG, UCLA, USC) to enable us to evaluate the consistency of 
CBF measurements across multiple sites and to ensure that the recruitment target of 10 subjects will be met in 
time to allow for the subsequent NIH grant submission in 2017.  
 
Figure 1. Overview of Study Design 
 
4.  
SUBJECT SELECTION CRITERIA 
The Target Population are subjects between 30 – 90 years of age with stroke within the previous 30 days that 
is attributed to 70-99% atherosclerotic stenosis of a major intracranial artery (carotid, middle cerebral, vertebral 
or basilar). The full inclusion and exclusion criteria are similar to the SAMMPRIS trial 8 (referred to in section 1 
above) with the following exceptions: 1) Subjects with TIA will be excluded because of their excellent outcome 
on AMM in SAMMPRIS.10 2) The upper age limit in this pilot is 90 rather than 80, given the positive response to 
RLIC in octogenarians in the 2nd Chinese trial.17 3) CT angiography (CTA) or magnetic resonance angiography 
(MRA) measurements of 70-99% intracranial stenosis will be sufficient for enrollment in this study, whereas 
catheter angiography was required in SAMMPRIS. (Catheter angiography is expensive and has some risk that 
is difficult to justify in a medical management trial). 4) Diabetic subjects taking sulfonylureas will be excluded 
because these drugs block ATP-sensitive potassium channels that are thought to play a key role in the 
protective effect of RLIC.18  The full inclusion and exclusion criteria for this pilot study are provided below. 

 
 
5
Inclusion Criteria: 
1. Symptomatic cerebral infarction within 30 days of enrollment attributed to 70-99% stenosis of a major 
intracranial artery (carotid artery, MCA stem (M1), vertebral artery, or basilar artery) that is documented by 
any of the following: MRA, CTA, or catheter angiography. Percent stenosis will be measured according to 
WASID criteria (= 1 – [Ds / Dn]) x 100% with Ds [diameter of stenosis] and Dn [diameter of normal 
vessel]).19  
2. Modified Rankin score of ≤ 3 
3. Age ≥ 30 years and ≤ 90 years.  
 
Subjects 30-49 years are required to meet at least one additional criteria (i-vi) provided in the table 
below to qualify for the study. This additional requirement is to increase the likelihood that the 
symptomatic intracranial stenosis in subjects 30-49 years is atherosclerotic.  
i.  insulin dependent diabetes for at least 15 years   
ii. at least 2 of the following atherosclerotic risk factors:  hypertension (BP > 140/90 or on antihypertensive 
therapy); dyslipidemia (LDL > 130 mg /dl or HDL < 40 mg/dl or fasting triglycerides > 150 mg/dl or on lipid 
lowering therapy); smoking; non-insulin dependent diabetes or insulin dependent diabetes of less than 15 
years duration;   family history of any of the following: myocardial infarction, coronary artery bypass, 
coronary angioplasty or stenting, stroke, carotid endarterectomy or stenting, peripheral vascular surgery 
in parent or sibling who was < 55 years of age for men or < 65 for women at the time of the event 
ii. history of any of the following: myocardial infarction, coronary artery bypass, coronary angioplasty or 
stenting, carotid endarterectomy or stenting, or peripheral vascular surgery for atherosclerotic disease 
iv. any stenosis of an extracranial carotid or vertebral artery, another intracranial artery, subclavian artery, 
coronary artery, iliac or femoral artery, other lower or upper extremity artery, mesenteric artery, or renal 
artery that was documented by non-invasive vascular imaging or catheter angiography and is considered 
atherosclerotic  
v. aortic arch atheroma documented by non-invasive vascular imaging or catheter angiography 
vi. any aortic aneurysm documented by non-invasive vascular imaging or catheter angiography that is 
considered atherosclerotic  
4. Negative pregnancy test in a female who has had any menses in the last 18 months 
5. Subject is willing and able to return in 30 days for close-out visit for the study   
6. Subject is available by phone 
7. Subject is able to apply the conditioning device or has access to another person (family member, friend) 
who can assist with application of conditioning device if needed 
8. Subject understands the purpose and requirements of the study, can make him/herself understood, and 
has provided informed consent 
9. Subject is able to undergo brain MRI  
 
Exclusion Criteria: 
1. Previous treatment of target lesion with a stent, angioplasty, or other mechanical device, or plan to perform 
one of these procedures 
2. Plan to perform concomitant angioplasty or stenting of an extracranial vessel tandem to an intracranial 
stenosis 
3. Intracranial tumor (except meningioma) or any intracranial vascular malformation 
4. Thrombolytic therapy within 72 hours prior to enrollment 
5. Progressive neurological signs within 24 hours prior to enrollment 
6. Any intracranial hemorrhage (parenchmal, subarachnoid, subdural, epidural) within 90 days 
7. Any untreated chronic subdural hematoma  

 
 
6
8. Intracranial arterial stenosis due to arterial dissection, Moya Moya disease; any known vasculitic disease; 
herpes zoster, varicella zoster or other viral vasculopathy; neurosyphilis; any other intracranial infection; 
any intracranial stenosis associated with CSF pleocytosis; radiation induced vasculopathy; fibromuscular 
dysplasia; sickle cell disease; neurofibromatosis; benign angiopathy of central nervous system; post-
partum angiopathy; suspected vasospastic process, suspected recanalized embolus 
9. Presence of any of the following unequivocal cardiac sources of embolism: chronic or paroxysmal atrial 
fibrillation, mitral stenosis, mechanical valve, endocarditis, intracardiac clot or vegetation, myocardial 
infarction within three months,  dilated cardiomyopathy, left atrial spontaneous echo contrast, ejection 
fraction less than 30% 
10. History of upper extremity ischemia, known subclavian or brachial artery stenosis, subclavian steal 
syndrome, any upper extremity soft tissue, orthopedic or vascular injury, or mastectomy or other procedure 
that may contraindicate taking blood pressure or having a cuff on the arm for the conditioning treatment 
11. Difference in systolic blood pressure of > 15 mm Hg between both arms 
12. Known allergy or contraindication to aspirin or clopidogrel   
13. Active peptic ulcer disease, major systemic hemorrhage within 30 days, active bleeding diathesis, platelets 
< 100,000, hematocrit < 30, INR > 1.5, clotting factor abnormality that increases the risk of bleeding, 
current alcohol or substance abuse, uncontrolled severe hypertension (systolic pressure > 180 mm Hg or 
diastolic pressure > 115 mm Hg), severe liver impairment (AST or ALT > 3 x normal, cirrhosis), subject on 
dialysis 
14. Major surgery (including open femoral, aortic, or carotid surgery, cardiac) within previous 30 days or 
planned in the next 30 days after enrollment 
15. Indication for warfarin or heparin beyond enrollment  (NOTE: exceptions allowed for subcutaneous 
heparin for deep vein thrombosis (DVT) prophylaxis while hospitalized) 
16. Diabetic subjects taking sulfonylurea drugs 
17. Severe neurological deficit that renders the subject incapable of living independently 
18. Dementia or psychiatric problem that prevents the subject from following the protocol reliably 
19. Co-morbid conditions that may limit survival to less than 3 months 
20. Pregnancy or of childbearing potential and unwilling to use contraception for the duration of this study 
21. Claustrophobia requiring sedation for MRI or any metallic implants or MRI incompatible devices that do not 
permit the patient to have an MRI 
22. Enrollment in another study that would conflict with the current study 
 
5. 
SCREENING, INFORMED CONSENT, RANDOMIZATION AND ENROLLMENT OF SUBJECTS 
Subjects will be screened from the inpatient and outpatient stroke service at all four participating sites.  All 
eligibility criteria are determined by evaluations performed as routine standard of care. The principles of 
Informed Consent, according to FDA Regulations and ICH guidelines on GCP, will be followed. Each 
Investigator will submit a copy of the proposed consent form, together with the study protocol, to the 
appropriate IRB for approval. All subjects must provide informed consent to participate and only the participant 
can provide informed consent, which must be cosigned by a study investigator. Once a subject’s eligibility has 
been confirmed by the site investigators, the subject will be approached to participate in the trial. The consent 
form includes a section describing a screening process whereby the subject will have a test RLIC treatment 
with the Doctormate device (Figure 2) with inflation of the blood pressure cuffs on both arms simultaneously to 
a SBP of 200 mmHg for 5 minutes to ensure that the subject can tolerate the treatment. Subjects who cannot 
tolerate the treatment will be called by the study coordinator at 1 week but will not participate further in the trial. 
If the subject can tolerate the screening treatment and wishes to participate in the trial, the coordinator will 
email the study statistician at MUSC who will provide the randomized treatment assignment by email.  
 
6. 
RLIC DEVICE AND ISCHEMIC CONDITIONING REGIMEN 
The RLIC device in this pilot (called Doctormate) will be donated by the company that provided the device for 
the Chinese pilot studies. Dr. David Hess (co-investigator in this study) obtained an amendment to an existing 
IDE approval from the FDA (G140239) to use this device in a small IRB-approved pilot study at MCG and 

 
 
7
MUSC in late 2015. The purpose of that pilot study was to obtain initial experience with the Doctormate device. 
In that study, 4 subjects with symptomatic ICAS (1 at MUSC, 3 at MCG) were treated with daily BUE RLIC (4 
cycles of 5-minute inflations to a pressure of 200 mm Hg with 5 minutes of reperfusion between each inflation) 
for 30 days to assess their tolerance of the procedure. CBF and biomarkers were not performed. The subject 
at MUSC performed RLIC daily for 7 days and tolerated each treatment well but then developed unilateral wrist 
pain (unrelated to active treatment). Subsequent measurements of blood pressure and pulses in both arms 
were similar. The subject was willing to continue treatment but, because this was a preliminary feasibility study, 
Dr. Chimowitz decided not to continue the subject’s treatment to 30 
days. The 3 subjects enrolled at MCG tolerated the treatment well 
with 30-day treatment adherence rates of 100%, 90% and 85%. Drs. 
Chimowitz and Hess have also personally used the RLIC device 
daily for 14 days (see Figure 2) and were easily able to tolerate the 
mild symptoms produced by the treatment (paresthesia, mild 
cyanosis of fingers). Dr. Hess has now applied to the FDA to extend 
the IDE approval to cover the pilot study proposed in this protocol.  
 
Rationale for the RLIC regimen in this study. Each daily bilateral 
upper extremity RLIC treatment will consist of 4 cycles of 5-minute 
inflations of both blood pressure cuffs simultaneously to a pressure 
of 200 mm Hg with 5 minutes of reperfusion between each inflation 
using the Doctormate device (see Figure 2). The selection of 4 
cycles of 5-minute duration for the daily RLIC treatment is based on 
the initial ischemic preconditioning study in canine hearts by Murry 
in 1986 that established the effectiveness of this regimen.20 
Moreover, in terms of acute cardioprotection, pre-clinical studies have shown that 4 to 6 cycles of 5-minute 
durations appear optimal.21 Using 4 cycles instead of 5 cycles (the regimen used in the Chinese trials 16,17) will 
lessen the total duration of each treatment from 45 minutes to 35 minutes, which we expect will increase 
adherence.  We chose to measure changes in CBF and biomarkers at 30 days for this pilot study because 
some preliminary human studies by the MCG group show that CBF increases within 6-24 hours of first use of 
RLIC, and a preclinical study (in a mouse model) shows that the increased CBF after RLIC is sustained to 28 
days with daily RLIC treatment.12 Moreover, the first 30 days after enrollment in SAMMPRIS was the highest 
risk period for recurrent stroke so it is important to determine if the CBF and biomarker responses to RLIC 
persist for this period.  
 
7. 
AGGRESSIVE MEDICAL MANAGEMENT 
 
The medical management for all subjects enrolled in this pilot study will consist of the current standard of care 
recommended by the American Heart Association and American Stroke Association for patients with ICAS 
established by the SAMMPRIS trial.22 This consists of dual antiplatelet therapy (aspirin 325 mg per day, 
clopidogrel 75 mg per day) and intensive risk factor management targeting a systolic blood pressure < 140 mm 
HG, an LDL cholesterol < 70 mg /dl, non-HDL cholesterol < 100mg/dl, smoking cessation, and hemoglobin A1c 
< 7% in diabetics.  
 
8. 
BLOOD BIOMARKER MEASUREMENTS  
The blood biomarkers that will be measured are putative biomarkers of RLIC 23-27   and known inflammatory and 
fibrinolytic markers associated with the development or progression of ICAS, or increased risk of stroke in 
patients with ICAS 28-31. These consist of: Nitrite, IL-10, SDF1, Micro RNA 144, Lp-PLA2, IL-6, hsCRP, Soluble 
E-selectin, ICAM, MMP-9, PAI-1, tPA, and ADMA. We will measure the blood biomarkers at baseline and 
close-out (33-35 days after enrollment) in all 10 subjects. All blood biomarkers will be mailed to the Blood 
Biomarker Core at MCG where the levels of biomarkers will be measured blinded to site, subject, treatment 
assignment and time point. 
Figure 2. The RLIC device used in the 
Chinese trials will be used in this pilot study 
and is shown being applied to Dr. David 
Hess, a Co-PI of this pilot study at Georgia 
Regents University (center)  

 
 
8
9. 
MRI MEASUREMENTS OF CBF AND OTHER PERFUSION PARAMETERS 
ASL MRI will be used to provide quantitative measurements of CBF in all 10 subjects in the study (at baseline 
and at close-out). 32,33 ASL does not require the injection of contrast material and can be repeated over time 
without risk to patients. We will use a standardized ASL protocol agreed upon by the study radiologists 
and physicists at the 4 participating sites that can be applied to different MRI scanner platforms.34 Each 
subject will undergo all MR studies for this pilot on the same scanner to limit slights variations in images 
from scanner to scanner. We have already tested the feasibility of using our planned ASL MRI protocol under a 
MCG / UCLA IRB-approved protocol. Six subjects with recent stroke from ICAS underwent ASL MRI before 
and after one RLIC treatment, a mean of 4.6 hours apart. The de-identified scans were sent to UCLA where 
Dr. Liebeskind performed CBF analyses and readings blinded to pre- and post-RLIC treatment. After just 1 
cycle of RLIC, these subjects showed mean increases of CBF of 8%-28% in the MCA and PCA territories on 
the infarct side vs. the normal side.  While quantitative CBF obtained with ASL MRI is the primary MR outcome 
in this pilot, we will also utilize dynamic susceptibility contrast enhanced perfusion MR imaging (DSC-PWI) to 
assess the effectiveness of secondary brain perfusion parameters (such as cerebral blood volume and 
cerebrovascular transit times).    
10. 
ASSESSMENT OF FEASIBILITY, TOLERABILITY AND ADHERENCE TO RLIC 
Enrolled subjects randomized to the RLIC group will take the Doctormate device home and use it daily for the 
next 30 days. The research coordinator will call the subject weekly up until the close-out visit to document any 
problems with the device or any adverse events using a questionnaire (see Appendix 1). The subject will also 
be asked to keep a daily diary for the 30 days the Doctormate device is used (see appendix 2.) The device 
records when it is used and whether the treatment was completed so when the subject returns for the close-out 
visit, we will be able assess adherence to use of the device.  
11. 
RANDOMIZATION, BLINDING, AND DATA MANAGEMENT 
 
Subjects will be randomized 1:1 using a pre-generated exact central randomization list that controls for 
moderate imbalances at the site level. All study data will be entered directly by either the study PI or stroke 
coordinator at each site in the RedCap data management system developed at MUSC for the study. Initial data 
checking will be performed by the system before the data can be saved to prevent low level data errors. When 
the data are transferred to the study biostatistician for analysis and report generation, further data quality 
checks will be conducted by SAS. Study data will be retained on a secure server at the Department of Public 
Health Sciences at MUSC.  
12. 
STATISTICAL ANALYSES 
To estimate the variability in CBF and biomarkers, all of which are continuous measures, simple summary 
statistics will be reported for the baseline and close-out measurements in each group. With five imaging 
samples per group, the precision of the 90% confidence interval around the mean would be ± 0.95 for a SD of 
1, and, as an example, would increase to ± 7.63 for a SD of 8. We will also evaluate the changes in CBF and 
biomarkers from baseline to close-out in the two groups using means and 90% confidence intervals. Here, the 
precision of the resulting confidence interval is ± 9.4 when the SD is 8; that is, if RLIC yields a mean 10% 
change in CBF and sham RLIC yields a mean 0% change in CBF the resulting 90% confidence interval is (0.6, 
19.4) for the difference in percent change in CBF. Finally, with a sample size of N=5, we will be able to 
estimate the correlation between CBF and biomarkers for each arm with an 90% confidence interval of 0.5 (-
0.5, 0.9) in the case of an observed moderate correlation. Interpretation of the summary statistics will be 
complimented with graphical approaches including boxplots to assess distributions within treatment arms, and 
funnel plots to assess differences at the site level.  
 
13.  
PROTECTION OF HUMAN SUBJECTS 
Risks to the Subjects: The risks of the Doctormate device might include discomfort, numbness or tingling in 
the hands and arms when the device is inflated, and a warm feeling when it is deflated. The device may also 
cause bruising in the arm or petechiae. There is also the theoretical possibility of a small risk of a venous clot 

 
 
9
forming in the arm. However, in our review of the literature we have not found any reports of blood clot 
formation with RLIC and there were no instances of venous thrombosis or any serious adverse event in either 
of the two published trials in China. 16,17 In one of those trials, 30 subjects over age 80 used the Doctormate 
device twice per day on both arms for 6 months and the following risks were noted in that trial: “Transient 
sporadic petechiae were observed in 3 cases during the first 30 days of the study, but disappeared soon after 
without discontinuing treatment. No ecchymosis, tenderness to palpation, edema, skin breakage, or other skin 
lesions were observed. No deep vein thromboses were detected by vascular sonography during or at the end 
of the 180 days of treatment”.17  In our pilot trial, we will only be using the device once per day for a period of 
30 days, which is a considerably lower dose than previously used in the two Chinese trials. In both animal and 
human experiments for cardiac or brain conditioning, there are no examples where RLIC increased CBF above 
normal levels or resulted in intracerebral hemorrhage.  
 
Risk Analysis and Risk Mitigation 
 
All SAEs and any deaths will be reported to the Institutional Review Board within 24 hours. 
The risks related to participation in this trial are related to the a) RLIC device; b) MRI scan; c) phlebotomy; d.) 
medications associated with AMM; and e) loss of confidentiality. 
a.) Device related. Although we don’t anticipate any serious adverse events related to the RLIC device 
based on experience with the same device in two Chinese trials 16,17 , patient safety is of paramount 
importance in this trial and there are operations in place for monitoring adverse events (see Protection 
Against Risk below). The risks that are possibly anticipated with the RLIC device include: 
 
Petechiae on the arm 
 
Skin rash or hypersensitivity to the cuff 
 
Thrombosis of veins in arm 
 
Swelling of the arm 
 
Pain and discomfort in the arm 
 
Muscle or nerve injury in the arm 
 
b.) The risks that are associate with MRI include 
 
Claustrophobia and anxiety from the MRI  
 
c.) The risks associated with phlebotomy are  
 
Discomfort or bruising of an arm from venipuncture required for biomarkers and routine blood 
tests 
 
d.) All of the medications used in this study (aspirin and clopidogrel and the medications to control risk 
factors) have been approved by the Food and Drug Administration (FDA) for the conditions for which 
they will be prescribed in this study and are not investigational. The major side effects of aspirin are 
major hemorrhage and peptic ulceration. Other possible side effects of aspirin include heartburn, 
ringing in the ears, nausea and vomiting. The most common side effects of clopidogrel are skin rash, 
bruising, itching, nausea, vomiting, diarrhea, intestinal discomfort. A less common but more serious 
side effect of clopidogrel is major gastrointestinal or brain hemorrhage. The most serious side effect of 
clopidogrel is a clotting disorder called thrombotic thrombocytopenic purpura (TTP) but this is very rare 
(1 in 15,000-20,000 treated subjects). The  combination of clopidogrel and aspirin is commonly used for 
90 days after stroke or TIA in patients with intracranial stenosis following the SAMMPRIS trial 9 and will 
be prescribed for the duration that subjects participate in this pilot study (33-35 days). The combination 
of aspirin and clopidogrel is associated with a significantly higher risk of major bleeding compared with 
clopidogrel or aspirin alone. The risks associated with statin therapy are a persistent increase in liver 
enzymes (0.0 - 0.4%), myalgia (2.8%), muscle weakness with increase in CK levels > 10 x upper limit 
of normal (0.03 - 0.1%), and rarely rhabdomyolysis that can potentially lead to renal failure. The risks 
associated with antihypertensive medications include hypotension, dizziness, headaches, weakness, 

 
 
10
allergic reactions, diarrhea, hypokalemia or hyperkalemia depending on the type of blood pressure 
medication taken, cough (with ACE inhibitors), and angioedema (ACE inhibitors).  
 
e.) There is the risk of loss of confidentiality 
 
The principles of Informed Consent, according to FDA Regulations and ICH guidelines on GCP, will be 
followed. All subjects must provide informed consent to participate and only the participant can provide 
informed consent, which must be cosigned by a study investigator. Once a subject’s eligibility has been 
confirmed by the site investigators, the subject will be approached to participate in the trial. The consent form 
includes a section describing a screening process whereby the subject will receive one session of RLIC 
treatment lasting 5 minutes to ensure that the subject can tolerate the treatment. Subjects who cannot tolerate 
the treatment will be called by the study coordinator at 1 week but will not participate further in the trial. Only 
subjects who can tolerate the screening treatment will be randomized to one of the treatment arms.   
 
Protection Against Risk 
The research coordinator will call subjects randomized to the RLIC group weekly and will use a standardized 
questionnaire to ask subjects about adverse events (see Appendix 1). For the pain question, we will utilize a 
visual analog pain scale of 0 to 10 and provide this to the subjects randomized to the RLIC group. At the 
weekly phone call, the research coordinator will ask the degree of pain using this scale. If the score is > 2, the 
site investigator will be notified and will contact the subject by phone to review the level of discomfort. 
Additionally, If the subject answers “yes” to any other questions, we will ask the subject to come in to be 
examined.   If we suspect a venous thrombosis because of swelling or pain, we will perform a venous 
ultrasound to rule out a deep venous thrombosis. We will also obtain the phone number of a relative or friend in 
order to reach the subject if we have trouble reaching the subject.  All subjects will be given the telephone 
numbers of the principal site neurologist and site coordinator to report any clinical events or to ask questions 
about the study. 
Subjects who are claustrophobic will not be enrolled in this study. To reduce the risk of phlebotomy, only 
trained phlebotomists will perform venipuncture. All neuroimaging and biomarker data will be de-identified as 
stated under “Sources of Material”. Copies of the source documents used to collect data for study subjects will 
be kept in confidential binders at the participating sites. All these measures will ensure against loss of 
confidentiality. 
 
Side effects of any medications prescribed to subjects as part of routine care of subjects with intracranial 
stenosis will also be monitored. These side effects will be minimized by recommending use of enteric-coated 
aspirin, checking liver enzymes and CK for subjects on a statin if clinically indicated, and instituting appropriate 
treatment should side effects arise.  
 
 
Potential Benefits of the Proposed Research to the Subjects and Others.  Subjects enrolled in this study 
may benefit from the increased medical supervision that occurs by participating in this study; however, no 
benefit from this supervision or the RLIC treatment can be guaranteed. If RLIC is indeed effective as 
suggested in the previous Chinese trials, 16,17 the subjects randomized to RLIC may have a reduction in stroke. 
Based on previous human studies, there are minimal risks to RLIC 16,17 and there is the potential that this 
treatment could ultimately be shown to be effective for lowering the risk of stroke in patients with ICAS, one of 
the highest risk stroke-prone conditions.   
Importance of the Knowledge to be Gained.  The risk of recurrent stroke in patients with ICAS is very high, 
about 20% at one year even with aggressive medical management (AMM). 10 RLIC has the potential to reduce 
this risk of stroke and avoid disability for patients with ICAS based on the preliminary trials performed in China. 
16,17 Since the anticipated risks of RLIC are low, these risks are reasonable in relation to the importance of the 
knowledge that will be gained from this study. This study will provide key pilot data to evaluate the tolerability 
and adherence to RLIC and will enable calculation of the sample size for a subsequent larger NIH-funded 

 
 
11
multicenter Phase I / II trial that will provide more rigorous data on the mechanisms of action of RLIC and the 
potential efficacy of RLIC in preventing stroke in these subjects. If these two goals are achieved in the Phase I 
/ II trial, we will submit another grant to NIH to fund a definitive large multicenter Phase III trial to establish the 
efficacy of RLIC for subjects with ICAS. If that planned trial is positive for RLIC, it will lead to a new treatment 
for this common and high-risk disease and will provide a strong rationale to test RLIC for related conditions 
such as patients with extracranial carotid stenosis and patients with vascular cognitive impairment 
Safety Monitoring.  Fenwick Nichols MD, Professor of Neurology at the Medical College of Georgia, will serve 
as the Safety Officer.  Dr. Nichols has over 30 years of experience as a vascular neurologist, is Board Certified 
in Internal Medicine and Neurology, and served as the Safety Officer for a past trial of minocycline in acute 
ischemic stroke conducted at the Medical College of Georgia, and two other sites.  All adverse events (AE) and 
serious adverse events (SAEs) will be reported to Dr. Nichols and the site’s IRB within 24 hours. A SAE is 
defined by any medical experience regardless of its relationship to the investigational device or study drugs 
that occurs during subject enrollment in this trial that results in any of the following: (1) inpatient hospitalization 
or prolongation of a hospitalization; (b) persistent or significant disability/incapacity; (c) death of the study 
subject, or (d) necessitates an intervention to prevent a permanent impairment of a body function or permanent 
damage to a body structure. Dr. Nichols will make a determination of whether an AE or SAE in any way is 
related to the Doctormate device.  
 
Stopping rules: If the Safety Officer determines that an SAE is definitely related to the device, the study will be 
stopped and a review will be conducted by the safety monitor of the outcomes of all enrolled subjects, who will 
determine whether enrollment in the study can be restarted.   Since there are only 10 subjects that will be 
enrolled in this pilot study, this decision to restart enrollment cannot be based on a formal statistical stopping 
rule. Instead it will be based on a clinical impression of likely harm to subjects from continuing ischemic 
conditioning, which the evidence from much larger completed trials of ischemic conditioning in subjects  with 
coronary and intracranial occlusive disease suggests is very unlikely. 16,17,35 
 
 

 
 
12
Bibliography 
 
1. 
Sacco RL, Kargman DE, Gu Q, Zamanillo MC. Race-ethnicity and determinants of intracranial 
atherosclerotic cerebral infarction. The Northern Manhattan Stroke Study. Stroke. 1995; 26(1):14-20. 
2. 
Qureshi AI, Safdar K, Patel M, Janssen RS, Frankel MR. Stroke in young black patients. Risk factors, 
subtypes, and prognosis. Stroke. 1995; 26(11):1995-8.  
3. 
Weisberg LA. Clinical characteristics of transient ischemic attacks in black patients. Neurology. 
1991;41(9):1410-4.  
4. 
Wityk RJ, Lehman D, Klag M, Coresh J, Ahn H, Litt B. Race and sex differences in the distribution of 
cerebral atherosclerosis. Stroke. 1996; 27(11):1974-80.  
5. 
Feldmann E, Daneault N, Kwan E, Ho KJ, Pessin MS, Langenberg P, Caplan LR. Chinese-white 
differences in the distribution of occlusive cerebrovascular disease. Neurology. 1990;40(10):1541-5.  
6. 
Williams AO, Resch JA, Loewenson RB. Cerebral atherosclerosis--a comparative autopsy study between 
Nigerian Negroes and American Negroes and Caucasians. Neurology. 1969;19(3):205-10.  
7. 
Chimowitz MI, Lynn MJ, Howlett-Smith H, Stern BJ, Hertzberg VS, Frankel MR, Levine SR, Chaturvedi S, 
Kasner SE, Benesch CG, Sila CA, Jovin TG, Romano JG; Warfarin-Aspirin Symptomatic Intracranial 
Disease Trial Investigators. Comparison of warfarin and aspirin for symptomatic intracranial arterial 
stenosis. N Engl J Med 2005; 352(13):1305-16.  
8. 
Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, Janis LS, Lutsep HL, Barnwell SL, 
Waters MF, Hoh BL, Hourihane JM, Levy EI, Alexandrov AV, Harrigan MR, Chiu D, Klucznik RP, Clark 
JM, McDougall CG, Johnson MD, Pride GL Jr, Torbey MT, Zaidat OO, Rumboldt Z, Cloft HJ; SAMMPRIS 
Trial Investigators. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J 
Med 2011;365(11):993-1003. PMCID: PMC3552515. 
9. 
Derdeyn CP, Chimowitz MI, Lynn MJ, Fiorella D, Turan TN, Janis LS, Montgomery J, Nizam A, Lane BF, 
Lutsep HL, Barnwell SL, Waters MF, Hoh BL, Hourihane JM, Levy EI, Alexandrov AV, Harrigan MR, Chiu 
D, Klucznik RP, Clark JM, McDougall CG, Johnson MD, Pride GL Jr, Lynch JR, Zaidat OO, Rumboldt Z, 
Cloft HJ, for the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in 
Intracranial Stenosis Trial Investigators. Aggressive medical treatment with or without stenting in high-risk 
patients with intracranial arterial stenosis (SAMMPRIS): the final results of a randomized trial. Lancet 
2014; 383(9914):333-41. PMCID: PMC3971471. 
10. Al Kasab S, Lynn MJ, Turan TN, Derdeyn CP, Fiorella D, Lane BF, Janis LS, Chimowitz MI; SAMMPRIS  
Investigators. Impact of the New American HeartAssociation/American Stroke Association Definition of 
Stroke on the Results of the Stenting and Aggressive Medical Management for Preventing Recurrent 
Stroke in Intracranial Stenosis Trial. J Stroke Cerebrovasc Dis. 2016 Oct 17. pii:S1052-3057(16)30310-X. 
doi: 10.1016/j.jstrokecerebrovasdis.2016.08.038. [Epub ahead of print] PubMed PMID: 27765556. 
11. Hess DC, Hoda MN, Bhatia K. Remote limb preconditioning and postconditioning: Will it translate into a 
promising treatment for acute stroke? Stroke 2013; 44:1191-7. 
12. Khan MB, Hoda MN, Vaibhav K, Giri S, Wang P, Waller JL, Ergul A, Dhandapani KM, Fagan SC, Hess 
DC. Remote ischemic postconditioning: Harnessing endogenous protection in a murine model of vascular 
cognitive impairment. Transl Stroke Res. 2015;6:69-77. PMCID: PMC4297613. 
13. Hoda MN, Bhatia K, Hafez SS, Johnson MH, Siddiqui S, Ergul A, Zaidi SK, Fagan SC, Hess DC. Remote 
ischemic perconditioning is effective after embolic stroke in ovariectomized female mice. Transl Stroke 
Res 2014; 5(4):484-90. PMCID: PMC4092232. 
14. Hoda MN, Siddiqui S, Herberg S, Periyasamy-Thandavan S, Bhatia K, Hafez SS, Johnson MH, Hill WD, 
Ergul A, Fagan SC, Hess DC. Remote ischemic perconditioning is effective alone and in combination with 
intravenous tissue-type plasminogen activator in murine model of embolic stroke. Stroke 2012;43:2794-9. 
PMCID: PMC3740528. 
15. Hoda MN, Fagan SC, Khan MB, Vaibhav K, Chaudhary A, Wang P, Dhandapani KM, Waller JL, Hess 
DC. A 2 x 2 factorial design for the combination therapy of minocycline and remote ischemic 
perconditioning: Efficacy in a preclinical trial in murine thromboembolic stroke model. Exp Transl Stroke 
Med 2014; 6:10. PMCID: PMC4204390. 
16. Meng R, Asmaro K, Meng L, Liu Y, Ma C, Xi C, Li G, Ren C, Luo Y, Ling F, Jia J, Hua Y, Wang X, Ding 
Y, Lo EH, Ji X. Upper limb ischemic preconditioning prevents recurrent stroke in intracranial arterial 
stenosis. Neurology. 2012; 79:1853-61. 

 
 
13
17. Meng R, Ding Y, Asmaro K, Brogan D, Meng L, Sui M, Shi J, Duan Y, Sun Z, Yu Y, Jia J, Ji X. Ischemic 
conditioning is safe and effective for octo- and nonagenarians in stroke prevention and treatment. 
Neurotherapeutics. 2015; 12(3): 667-77. PMID: 25956401; PubMed Central PMCID: PMC4489956. 
18. Loukogeorgakis SP, Williams R, Panagiotidou AT, Kolvekar SK, Donald A, Cole TJ, Yellon DM, Deanfield 
JE, MacAllister RJ. Transient limb ischemia induces remote preconditioning and remote postconditioning 
in humans by a K(ATP)-channel dependent mechanism. Circulation. 2007; 116(12): 1386-95. PubMed 
PMID: 17724264. 
19. Samuels OB, Joseph GJ, Lynn MJ, Smith HA, Chimowitz MI. A standardized method for measuring 
intracranial stenosis. Am J Neuroradiol 2000; 21:643-6. 
20. Murry CE, Jennings RB, Reimer KA. Preconditioning with ischemia: A delay of lethal cell injury in 
ischemic myocardium. Circulation. 1986; 74:1124-1136. 
21. Johnsen J, Pryds K, Salman R, Lofgren B, Kristiansen SB, Botker HE. The remote ischemic 
preconditioning algorithm: Effect of number of cycles, cycle duration and effector organ mass on efficacy 
of protection. Basic Res Cardiol. 2016; 111:10. 
22. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, 
Furie KL, Heck DV, Johnston SC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, 
Schwamm LH, Wilson JA; American Heart Association Stroke Council, Council on Cardiovascular and 
Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease.. Guidelines 
for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for 
healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 
2014;45(7): 2160-236. 
23. Rassaf T, Totzeck M, Hendgen-Cotta UB, Shiva S, Heusch G, Kelm M. Circulating nitrite contributes to 
cardioprotection by remote ischemic preconditioning. Circ Res. 2014; 114:1601-10. 
24. Hess DC, Hoda MN, Khan MB. Humoral mediators of remote ischemic conditioning: important role of 
eNOS/NO/Nitrite. Acta Neurochir Suppl. 2016; 121:45-8. PMID: 26463921. 
25. Davidson SM, Selvaraj P, He D, Boi-Doku C, Yellon RL, Vicencio JM, Yellon DM. Remote ischaemic 
preconditioning involves signalling through the SDF-1α/CXCR4 signalling axis. Basic Res Cardiol. 2013; 
108(5):377. 
26. Cai ZP, Parajuli N, Zheng X, Becker L. Remote ischemic preconditioning confers late protection against 
myocardial ischemia-reperfusion injury in mice by upregulating interleukin-10. Basic Res Cardiol. 
2012;107:277. 
27. Li J, Rohailla S, Gelber N, Rutka J, Sabah N, Gladstone RA, Wei C, Hu P, Kharbanda RK, Redington AN. 
MicroRNA-144 is a circulating effector of remote ischemic preconditioning. Basic Res Cardiol. 2014; 
109(5):423. 
28. Frankel MR, Quyyumi A, Yize Z, Long Q, Le NA, Waller EK, Lynn M, Arenillas JF, Lane B, Chimowitz M. 
Biomarkers of Ischemic Outcomes in Symptomatic Intracranial Stenosis (BIOSIS) - preliminary results. 
Stroke. 2014;45:ATMP33. 
29. Arenillas JF, Alvarez-Sabin J, Molina CA, Chacon P, Fernandez-Cadenas I, Ribo M, Delgado P, Rubiera 
M, Penalba A, Rovira A, Montaner J. Progression of symptomatic intracranial large artery atherosclerosis 
is associated with a proinflammatory state and impaired fibrinolysis. Stroke. 2008; 39:1456-1463. 
30. Massot A, Pelegri D, Penalba A, Arenillas J, Boada C, Giralt D, Ribó M, MolinaCA, Rosell A, Alvarez-
Sabín J, Chacón P, Rovira A, Delgado P, Montaner J. Lipoprotein-associated phospholipase a2 testing 
usefulness among patients with symptomatic intracranial atherosclerotic disease. Atherosclerosis. 2011; 
218:181-187. 
31. Lopez-Cancio E, Galan A, Dorado L, Jimenez M, Hernandez M, Millan M, Reverté S, Suñol A, Barallat J, 
Massuet A, Alzamora MT, Dávalos A, Arenillas JF. Biological signatures of asymptomatic extra- and 
intracranial atherosclerosis: The Barcelona-Asia (asymptomatic intracranial atherosclerosis) study. 
Stroke. 2012; 43:2712-2719. 
32. Wolf RL, Detre JA. Clinical neuroimaging using arterial spin-labeled perfusion magnetic resonance 
imaging. Neurotherapeutics. 2007; 4(3):346-59. 
33. Wang DJ, Alger JR, Qiao JX, Hao Q, Hou S, Fiaz R, Gunther M, Pope WB, Saver JL, Salamon N, 
Liebeskind DS. The value of arterial spin-labeled perfusion imaging in acute ischemic stroke: comparison 
with dynamic susceptibility contrast-enhanced MRI. Stroke. 2012; 43(4):1018-24. PMCID: PMC3314714. 

 
 
14
34. Alsop DC, Detre JA, Golay X, Gunther M, Hendrikse J, Hernandez-Garcia L, Lu H, MacIntosh B, Parkes 
L, Smits M, van Osch MJP, Wang DJJ, E.C. W, Zaharchuk G. Recommended Implementation of Arterial 
Spin Labeling Perfusion MRI for clinical applications: A consensus of the ISMRM Perfusion Study Group 
and the European ASL in dementia. Magn Reson Med. 2015; 73(1):102-16. doi:10.1002/mrm.25197. 
Epub 2014 Apr 8. Review. PubMed PMID: 24715426; PubMed Central PMCID: PMC4190138. 
35. Botker HE, Kharbanda R, Schmidt MR, Bottcher M, Kaltoft AK, Terkelsen CJ, Munk K, Andersen NH, 
Hansen TM, Trautner S, Lassen JF, Christiansen EH, Krusell LR, Kristensen SD, Thuesen L, Nielsen SS, 
Rehling M, Sorensen HT, Redington AN, Nielsen TT. 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; 375:727-34. 
 
 
 
 
 
 

 
 
15
Appendix 1.  
 
 
Adverse Event Questionnaire  
 
Subject Study Number ______________________________ 
 
End of Week (Circle one) 1._____,  2._____, 3. _____, 4. (close-out visit) _______ 
 
Date_____________  
 
1.) Have you experienced any swelling in either of your arms? (Y/N) 
Coordinator Comment: (if yes, specify which arm(s) and where in the arm(s), i.e., above, at or below 
cuff) 
 
2.) Have you had any discoloration (change in color) in either of your arms after any treatment? (Y/N) 
This could be redness, blueness, small red dots, red or purple blotches in your arm  
Coordinator Comment: (if yes, specify which arm(s), where in the arm(s), and type of discoloration) 
 
3.) Have you had any persistent tingling or numbness in either of your arms? (Y/N)  
Coordinator Comment: (if yes, specify which arm(s) and where in the arm(s))  
 
4.) During the cuff inflations or any time between use of the cuff, have you had pain in either arm? (Y/N) 
Coordinator Comment: if yes, ask subject to use visual analog pain scale given to subject after 
enrollment to rate the discomfort on the Pain scale between 0 and 10, and specify which arm(s) and 
where in the arm(s)is the pain located)          Pain rating__________ 
 
 
 
 

 
 
16
Appendix 2.  
 
 
Subject Diary 
 
Subject Study Number ____________________________ 
 
Day 
Completed? 
Y/N 
Pain in an Arm? 
Y/N Grade (0-
10) 
If yes, call 
coordinator 
Arm 
discoloration, 
swelling, or 
tingling? 
(Bruising, etc). 
Y/N 
If yes, call 
coordinator 
Specify type of problem or any 
other comments 
1 
 
 
 
 
2 
 
 
 
 
3 
 
 
 
 
4 
 
 
 
 
5 
 
 
 
 
6 
 
 
 
 
7 
 
 
 
 
8 
 
 
 
 
9 
 
 
 
 
10 
 
 
 
 
11 
 
 
 
 
12 
 
 
 
 
13 
 
 
 
 
14 
 
 
 
 
15 
 
 
 
 
16 
 
 
 
 
17 
 
 
 
 
18 
 
 
 
 

 
 
17
19 
 
 
 
 
20 
 
 
 
 
21 
 
 
 
 
22 
 
 
 
 
23 
 
 
 
 
24 
 
 
 
 
25 
 
 
 
 
26 
 
 
 
 
27 
 
 
 
 
28 
 
 
 
 
29 
 
 
 
 
30 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Research Coordinator Name and Contact Number:  
Principal Investigator Name and Contact Number: