Pilot, Randomized, Controlled, Staggered Start, Feasibility Trial of Ischemic Preconditioning, a Promising Novel Treatment for Stroke Prevention
Phase: NA
Conditions: Ischemic Stroke, Cerebral Small Vessel Disease, Cognitive Decline
Sponsor: University of California, Los Angeles

 
 
 
 
 
Remote Ischemic Preconditioning Over Time to Empower Cerebral Tissue (REM-PROTECT) 
 
NCT: 02169739 
 
March 8th, 2016  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
SUMMARY OF CHANGES DOCUMENT 
 
 
PROTOCOL: 
Remote Preconditioning Over Time to Empower Cerebral Tissue (REM-PROTECT) Clinical Trial 
 
 
RATIONALE FOR CHANGES 
1. 
Added Screening Phase for Device Tolerance 
After a subject consents to participate in the study, he/she will first participate in a study 
screening phase to ensure a basic level of tolerability of Remote Ischemic Conditioning 
(autoRIC™) device. The subject will undergo one full cycle of treatment under observation 
of the study team, including 4 cycles of alternating 5 minute inflation and 5 minute off periods.  
If the subject indicates willingness to continue receiving such treatment (screening success), 
she/she will enter the randomized trial phase, and be randomly allocated to the treatment or 
control group. If subject indicates unwillingness to continue receiving such treatment 
(screening failure), he/she will not advance to the randomized phase of the trial. Screen failure 
subjects will be followed up with a 3 day post-device screening phone call to ensure safety 
and obtain information regarding any adverse events.  
2. 
Changed Figure 5. Flow Diagram of the Study Design. This change reflects new changes 
in the clinical protocol (see below) 
3. 
Device Compliance added by Manufacturer.  

 

4 
 
 
 
 
PROTOCOL:  
Remote Preconditioning Over Time to Empower Cerebral Tissue (REM-PROTECT) Clinical Trial  
 
Version: B 
 
Date: March 8, 2016 
 
Overview of Protocol of REM-PROTECT 
 
Title 
REMote Preconditioning Over Time to Empower Cerebral Tissue 
(REM-PROTECT) 
Objective 
To evaluate remote limb ischemic preconditioning (RPreC) as a 
novel therapeutic strategy to prevent stroke, progressive ischemic 
brain injury, and cognitive decline in patients with moderate to 
severe cerebral small vessel ischemic disease. 
Study Design 
A single site, feasibility, dose-ranging randomized, medication-
device group 
Population Studied 
60 patients referred or seen at the UCLA clinic Inclusion criteria: 1) 
likely a lacunar stroke syndrome within the past 6 months, 2) age 
40-above, 3) absence of signs or symptoms of cortical dysfunction, 
4)MRI presence of a small subcortical ischemic, 5) white matter 
hyperintensity score of 2 (moderate) or 3 (severe) on the European 
Scale of Age-Related White Matter Change. 
 
Randomized Phase: Medical (control) or Remote Ischemic 
PreConditioning (RPreC) 
Device 
Automated Remote Ischemic Conditioning (autoRIC™) device and 
cuffs 
Number of Subject 
Enrolled 
3 
Number of Devices 
Shipped 
6 
 
 
A. Specific Aims 
 
The general aim of Remote Preconditioning Over Time to Empower Cerebral Tissue (REM-
PROTECT) is to evaluate remote limb ischemic preconditioning (RPreC) as a novel therapeutic 
strategy to prevent  stroke, progressive ischemic brain injury, and cognitive decline in patients 
with moderate to severe cerebral small vessel ischemic disease. A single site, feasibility dose-
ranging randomized clinical trial of RPreC will be performed.  
 
This is a feasibility early phase device trial to determine the feasibility of therapy adherence during 
chronic use before going to larger trial. Long-term compliance with this treatment with some 
nuisance aspects in a US small vessel stroke population is unknown and this fundamental piece of 

5 
 
information is needed to plan any subsequent trial. We want to test this technology and hope to 
achieve a goal of at least 75% or more compliance for physiologic targets.  
 
During periods of active treatment, RPreC will be induced twice a day by using the autoRIC™ 
device (which delivers four remote ischemic conditioning cycles of five minute intervals  followed 
by five-minutes of normal blood flow) around both upper body extremities. The RPreC 
intervention will be add-on therapy to guideline-based best standard medical prevention therapy. 
The study will have a randomized phase and a follow-up phase. 60 enrolled patients will be 
randomized 2:1 to best standard medical care plus active RPreC for 1 year and then follow-up for 
1 year versus best standard medical care alone for 1 year and then active RPreC for 1 year. Primary 
outcome measures will be obtained at the end of the first randomized year (staggered start RCT 
design). Successful completion of this trial will delineate the feasibility and safety, and explore 
biomarker indicators of potential efficacy, of inducing brain ischemic tolerance in small vessel 
stroke-prone patients. 
 
A.1. Specific Aim 1: Feasibility 
 
To establish the feasibility of remote ischemic preconditioning as a sustained therapy for 
prevention of ischemic brain injury from cerebral small vessel disease.    
 
This aim will be accomplished by demonstrating the remote ischemic preconditioning treatment 
can be successfully implemented with more than 75% adherence among enrolled patients 
throughout the 1-year of active treatment. Both patient self-report and remote physiologic 
monitoring will be performed to quantify patient behavioral adherence to the treatment regimen, 
and remote physiologic monitoring will be used to quantify physiologic attainment of brief 
ischemia states in the upper extremities. Establishment of feasibility will allow for subsequent 
larger, definitive clinical trials of RPreC as a treatment to confer long-term protection against 
ischemic brain injury due to cerebral small vessel disease.  
 
A.2. Specific Aim 2: Safety 
 
To determine the safety of remote ischemic preconditioning as a sustained therapy for prevention 
of ischemic brain injury from cerebral small vessel disease.    
 
This aim will be accomplished by assessing safety outcomes in patients undergoing remote 
ischemic preconditioning treatment. The primary safety endpoint will be all serious adverse events. 
Secondary safety endpoints will include deep and superficial vein thrombosis and all-cause 
mortality. Ascertainment that RPreC poses no major excess risk to patients will allow for 
subsequent efficacy testing in a larger clinical trial. 
 
A.3. Specific Aim 3: Signals of Efficacy 
 
To employ imaging biomarkers to demonstrate biologic efficacy of remote ischemic 
preconditioning as a sustained therapy for prevention of ischemic brain injury from cerebral small 
vessel disease, and to employ cognitive, ambulation, and clinical stroke event outcome measures 
to explore potential clinical efficacy. 
 
This aim will be accomplished by measuring volumetric progression of white matter ischemic 
injury on magnetic resonance imaging (biomarker efficacy) and cognitive battery performance, 

6 
 
ecologic ambulation assessment, and recurrent stroke events (clinical efficacy). MRIs will be 
performed at baseline and at 1 year (end of randomized phase) and several markers of injury 
progression assessed, including FLAIR hyperintensity volumetric burden (primary biomarker 
efficacy outcome), diffusion tensor imaging volumetric burden, and cerebral atrophy. Wireless 
sensors will be used to assess gait quantity and quality in real-world activity at baseline and 1 year. 
A cognitive battery sensitive to executive, attentional, and memory function, reflecting 
subcortical-frontal system integrity, will assess progression of vascular cognitive impairment. 
Lastly, clinical events during the year of randomized therapy will be compared across treatment 
arms, including ischemic stroke, transient ischemic attack, hemorrhagic stroke, myocardial 
infarction, and cardiovascular death.  
 
 
C. Trial Design  
 
C.1. Study Overview 
 
This is a single site, feasibility, randomized, dose-ranging clinical trial of remote ischemic 
preconditioning. During periods of active treatment, induced twice a day by using the autoRIC™ 
device around both upper body extremities which would deliver four remote ischemic conditioning 
cycles of five minute intervals  followed by five-minutes of normal blood flow. The RPreC 
intervention will be add-on therapy to guideline-based best standard medical prevention therapy. 
The study will have a randomized phase and a follow-up phase. 60 enrolled patients will be 
randomized 1:1:1 to 1 year of best standard medical care alone, best standard medical plus active 
once-daily RPreC, or best standard therapy plus active twice-daily RPreC. Following the 1 year 
randomized phase, the medical control group will cross over to once (10 patients) and twice (10 
patients) daily RPreC for 1 additional year (staggered start design, allowing for collection of 
additional feasibility and safety data and control group adherence to follow-up).  Primary outcome 
measures will be obtained at the end of the first randomized year. 
 
C.2. Technology 
 
Remote Ischemic Preconditioning Device: The autoRIC™   device is a new, portable, automated 
conditioning device, designed and developed by CellAegis Devices Inc., Canada. The device 
consists of a Control Unit, Charging Cradle, a Power Adaptor, a Wall Mount for the charging 
cradle (with wall plug and screws) and Applicator Cuffs. The control unit is a stand-alone reusable 
controller that controls the inflation and deflation cycles of the Applicator Cuff. The Control Unit 
clicks into the disposable Applicator Cuff when it is ready for use. The Applicator Cuff is a single-
used, disposable cuff that is fastened using Velcro into which a ‘one button’ battery-driven 
actuator system inserts. This provides for a mobile ‘point-of-care’ delivery of RIC that will not 
impose on other care delivery, and requires no special expertise for its use. The active device is 
programmed to inflate the cuff to 200 mmHg for five (5) minutes (ischemia) then be deflated for 
five (5) minutes (reperfusion) completing one cycle of ischemia-reperfusion; the RIC therapy 
cycle consists of a total of four (4) cycles of ischemia-reperfusion, which the autoRIC Device is 
programmed to automatically deliver. 
 
In this study, the device will be used with Applicator Cuffs bilaterally for 12 months to provide 
ischemic preconditioning therapy to the patient’s upper extremities. The applicator cuffs are 
available in three different adult sizes according to the SP10 standard (small, medium or large) and 
the cuff is selected to match the arm size of the patient. To assure a total cessation of blood flow 

7 
 
through the limb during the ischemic duration, the cuff inflation pressure is maintained at 200 mm 
Hg.  By Doppler ultrasound, it has been documented that inflation of the blood pressure cuff to 
200mm Hg causes cessation of blood flow in the arm1, 2. A total of four (4) inflation and deflation 
cycles will be applied in five (5) minute intervals twice a day. At the end of this automated 
process, the Procedure Complete indicator is illuminated and an audible tone is heard. The 
autoRIC™ will be used for 12 months to deliver remote ischemic conditioning to the patient. 
There have been no reported experiences of any side effects in preclinical and clinical studies. 
 
In addition to the autoRIC® Device, CellAegis Devices, Inc. developed the CRICtrac™ Mobile 
Application that allows the clinician and coordinators to monitor compliance of each individual 
study participant. Once the patient has been assigned to a treatment group, the coordinator will 
initialize new patient cuffs by scanning them using the CRICtrac™ Mobile App on a compatible 
Android smartphone equipped with a near-field antenna utilizing a Wi-Fi network connection. 
During the course of the trial or at the end of the trial, patient compliance can be monitored using 
the CRICtrac™ Data Portal providing that the cuff has been scanned. The compliance data is 
immediately uploaded to the CRICtrac™ Data Portal. The Data Portal can then be accessed via a 
link from the Mobile App or on any device with internet access. Once logged in, Trial Coordinators 
can view and/or export patient and trial information. 
C2.1. Device Training 
 
All participating investigators and site personnel that will be performing the autoRIC procedure 
will be trained in the use of the study device prior to participating in the study.  Device training 
will be conducted by the Principal Investigator. Training will be done according to the autoRIC 
User Manual and will include instructions on charging the device prior to the first use, recharging 
the device after each procedure, verifying the device is charged prior to each procedure, 
recognizing and addressing the different Warning/Error indications (e.g., battery light flashing 
blue, indicating that the battery is low but can still perform at least one procedure, battery light 
steady red, indicating battery low error – not enough battery power to run a complete procedure, 
etc.) and specific instructions for returning the device to the sponsor in the event of an error 
notification that cannot be addressed by the site personnel, or a failure of the device to charge after 
three hours.  
 
All device training will be documented in a training log that will be maintained in the site 
regulatory binder. 
 
C.3. Subjects 
 
60 subjects will be identified prior to discharge from the inpatient Stroke Service, which manages 
over 350 patients yearly, and from the inpatient rehabilitation unit that cares for 100 patients yearly 
with disabling stroke. They will also be identified in our outpatient stroke clinic that manages over 
500 patients yearly. Based upon a review of the past 5 years of stroke patients evaluated, we 
anticipate that at least 20% are likely to be eligible. Potential participants will be approached by 
an investigator and given the informed consent from to review. Enrolled subjects will be 
randomized 2:1 to active treatment (40 patients) and control (20 patients).  
 
C.3.1.Entry Criteria 
 
To enter the study screening phase, patients must meet all of the following inclusion and 
exclusion criteria: 

8 
 
 
Inclusion Criteria 
I. Clinical 
 
1. Clinical lacunar stroke syndrome within the past 6 months (from among the following 12 
syndromes as per SPS3 criteria: pure motor hemiparesis (PMH), pure sensory stroke, 
sensorimotor stroke, ataxic hemiparesis, dysarthria-clumsy hand syndrome, hemiballism, 
PMH with facial sparing, PMH with horizontal gaze palsy, PMH with contralateral III 
palsy, PMH with contralateral VI palsy, cerebellar ataxia with contralateral III palsy, pure 
dysarthria) 
2. Absence of signs or symptoms of cortical dysfunction 
3. No proximal large vessel atherosclerosis, intracranial atherosclerosis or cerebellar 
stroke. 
4. No major cardioembolic source requiring anticoagulation or other specific therapy 
 
II. Imaging 
 
1. MRI presence of a small subcortical ischemic per SPS criteria, any 1 or more of: 
a. Diffusion-weighted imaging lesion < 2.0cm in size at largest dimension and 
corresponding to the clinical syndrome.  
b. Well delineated focal hyperintensity <2.0 cm in size at largest dimension (including 
rostro-caudal extent) on FLAIR or T2 and clearly corresponding to the clinical 
syndrome. If other focal hyperintensities are present, the case will be discussed with 
the PI prior to randomization 
c. Multiple (at least 2) hypointense lesions of size 0.3-1.5 cm at largest dimension 
(including rostro-caudal extent) only in the cerebral hemispheres on FLAIR or T1 
in patients whose qualifying event is clinically hemispheric 
d. Well delinated hypointense lesion <1.5 cm in size at the largest dimension 
(including rostro-caudal extent) on FLAIR or T1 corresponding to the clinical 
syndrome. MRI must be done at least 1 months after the qualifying stroke 
2. Absence of cortical stroke and large (> 1.5cm) subcortical stroke, recent or remote 
3. White matter hyperintensity score of 2 (moderate) or 3 (severe) on the European Scale of 
Age-Related White Matter Change 
4. No evidence of cerebral amyloid angiopathy as per Boston Criteria. 
 
Exclusion Criteria 
 
To be eligible for entry into the study, none of the following criteria may be present:  
 
1. Disabling stroke (Rankin Scale ≥4)  
2. Previous intracranial hemorrhage (excluding traumatic) or hemorrhagic stroke 
3. Age under 40 years 
4. High risk of bleeding (e.g. recurrent GI or GU bleeding, active peptic ulcer disease, etc.) 
5. Anticipated requirement for long term use of anticoagulants (e.g. recurrent DVT)  
6. Prior cortical or retinal stroke (diagnosed either clinically or by neuroimaging), or other prior 
cortical or retinal TIA 
7. Prior ipsilateral carotid endarterectomy 
8. Impaired renal function: estimated GFR <40 

9 
 
9. Patients treated with hemodialysis 
10. Intolerance or contraindications to aspirin or clopidogrel (including thrombocytopenia, 
prolonged INR) 
11. Mini Mental Status Exam score < 24 (adjusted for age and education)  
12. Medical contraindication to MRI 
13.  Pregnancy or women of child-bearing age who are not following an effective method of 
contraception 
14. Pre-existing neurologic, psychiatric, or advanced systemic disease that would confound the 
neurological or functional outcome evaluations 
15. SBP <90 or > 200 
16. Known history of limb vascular disease, limb vascular bypass surgery, or limb deep venous 
thrombosis 
17. All women status post mastectomy (standard-of-care re: blood pressure proscription ipsilateral 
to prior mastectomy)  
18. Patients with a contraindication to taking blood pressure in the arm for any reason; 
19. Patients with a known bleeding disorder or known abnormality of blood flow to the limb. 
20. Patients with osteoporosis or other bone disorders 
21. Patients with peripheral nerve injury 
22. Patients with abnormal nerve supply 
23. Patients with peripheral neuropathy 
24. Patients with pre-existing traumatic injury to the limb. 
25. Prisoners 
26. Homeless individuals 
27. Patient unable to give informed consent and no available legally authorized representative to 
provide informed consent  
28.  Patient unlikely to be compliant with therapy/ unwilling to return for follow up visits 
29. Concurrent participation in another study with investigational drug or device treatment 
30. Other likely specific cause of stroke (e.g. dissection, vasculitis, prothrombotic diathesis, drug 
abuse) 
 
C.4. Enrollment and Consent 
 
After initial patient contact and assessment, the physician-investigator will review the patient’s 
relevant medical history and will verify the diagnosis of small subcortical stroke and moderate to 
severe WMH and determine eligibility for study entry according to inclusion and exclusion criteria 
above. Study participants who are competent or who have a legally authorized representative will 
be enrolled.  
 
C.6. Study Treatment 
 
Randomized Phase: Following signing of the consent form, the patient will be randomized and 
depending on randomization receive treatment with RPreC once daily, twice daily, or none for 1 
year. The RPreC procedure will consist of up to four 5-minute cycles of bilateral upper extremity 
ischemia, separated by 5-minute periods of reperfusion. Primary outcome measures will be 
obtained at 1 year. 
 
Follow-up Phase: Patients assigned to RPreC in the first year will exit the trial at the end of Year 
1. In contrast, patients assigned to the control arm in the first year will at the start of Year 2 enter 
a staggered therapy start phase, receiving active RPreC for 1 year (randomized 10 to once daily 

10 
 
and 10 to twice daily), and have additional outcome assessments. The additional data gathered in 
the Year 2 patients will provide more information regarding intervention feasibility and safety, 
and also promote adherence to the study protocol in Year 1.  
 
C.7. Concomitant Therapy 
 
All patients enrolled in this trial will receive intensive standard medical secondary prevention 
stroke treatment as per the recommendations of the AHA/ASA national Guidelines3. Patients may 
not be enrolled in another therapeutic clinical trial until after exit from REM-PROTECT after the 
two year visit. Patients may not be treated with other experimental stroke  therapies 
 
C.8.  Device Screening Phase 
 
After a subject consents to participate in the study, he/she will first participate in a study screening 
phase to ensure a basic level of tolerability of Remote Ischemic Conditioning (autoRIC™) device4. 
The subject will undergo one full cycle of treatment under observation of the study team, including 
4 cycles of alternating 5 minute inflation and 5 minute off periods.  If the subject indicates 
willingness to continue receiving such treatment (screening success), she/she will enter the 
randomized trial phase, and be randomly allocated to the treatment or control group. If subject 
indicates unwillingness to continue receiving such treatment (screening failure), he/she will not 
advance to the randomized phase of the trial. Screen failure subjects will be followed up with a 3 
day post-device screening phone call to ensure safety and obtain information regarding any adverse 
events. 
 
  

11 
 
Figure 5. Flow Diagram of the Study Design.  
 
 
C.9 Study visits  
 
Following the randomization assignment, all patients will have follow-up visits at 1, 3, 6, 9, and 
12 months. Feasibility, safety, and efficacy assessments will be performed at each of these visits, 
with the 12 month measures, at the conclusion of the randomized phase, constituting the primary 
outcome timepoint. In addition, the 20 control patients will have follow-up visits at 18 and 24 
months, during the period of their delayed start therapy. The cognitive assessment battery will be 
performed at the first qualifying visit to familiarize participants with the system before the baseline 
assessment at randomization and additionally at 1 month to assess whether any cognitive changes 
accompanied the initial RPreC effect. If participants ceased study treatment during the study, they 
will be encouraged to continue attending follow-up visits; all withdrawn participants will be 
invited to attend the closeout visit to reduce loss to follow-up.  
 
C.10. Treatment Evaluation 
 
C.10.1. Baseline Evaluation 
At study entry, enrolling investigator to record: 
• Demographic data (age, sex, vascular risk factors) 
• Heart rate 
• Blood pressure 
• Visual inspection of skin in arms, motor and sensory examinations of the hand  
• NIH Stroke Scale (NIHSS)  
• Modified Rankin Scale (mRS) 
• Barthel Index (BI) 
• EQ-5D (health-related quality of life) 
• Questionaire to verify stroke free status 
• Neurocognitive battery 
• MR imaging will be reviewed 
• Eligibility for enrollment 
• Review informed consent with patient 
 
C. 10.2. Day 30 Evaluation 
• Interval Events Form 
• Concomitant therapies form 
• Heart rate 
• Blood pressure 
• Visual inspection of skin in arms, motor and sensory examinations of the hand 
• NIH Stroke Scale (NIHSS)  
• Modified Rankin Scale (mRS) 
• Barthel Index (BI) 
• EQ-5D (health-related quality of life) 
• Questionaire to verify stroke free status 

12 
 
• Patient-reported Comfort Rating Scale — a 5 point Likert scale reflecting patient report 
of subjective experience of RPreC (very comfortable, comfortable, average, 
uncomfortable, very uncomfortable) (Wang X, Maurin M. Discomfort/Comfort 
assessment using an ordered category scale.)  
• Number of completed 5-minute cycles of RIPC 
• Neurocognitive battery 
 
C. 10.3. Month 3, 6, and 9 Evaluations 
• Interval Events Form 
• Concomitant therapies form 
• Heart rate 
• Blood pressure 
• Visual inspection of skin in arms, motor and sensory examinations of the hand  
• NIH Stroke Scale (NIHSS)  
• Modified Rankin Scale (mRS) 
• Barthel Index (BI) 
• EQ-5D (health-related quality of life) 
• Questionaire to verify stroke free status 
• Patient-reported Comfort Rating Scale — a 5 point Likert scale reflecting patient report 
of subjective experience of RPreC (very comfortable, comfortable, average, 
uncomfortable, very uncomfortable) (Wang X, Maurin M. Discomfort/Comfort 
assessment using an ordered category scale.)  
• Number of completed 5-minute cycles of RIPC 
• Neurocognitive battery 
• Accelerometer assessment of ecologic gait and activity 
 
C. 10.4. Year 1 Evaluation 
• Interval Events Form 
• Concomitant therapies form 
• Heart rate 
• Blood pressure 
• Visual inspection of skin in arms, motor and sensory examinations of the hand 
• NIH Stroke Scale (NIHSS)  
• Modified Rankin Scale (mRS) 
• Barthel Index (BI) 
• EQ-5D (health-related quality of life)  
• Questionaire to verify stroke free status 
• Patient-reported Comfort Rating Scale — a 5 point Likert scale reflecting patient report 
of subjective experience of RPreC (very comfortable, comfortable, average, 
uncomfortable, very uncomfortable) (Wang X, Maurin M. Discomfort/Comfort 
assessment using an ordered category scale.)  
• Number of completed 5-minute cycles of RIPC 
• Neurocognitive battery 
• Accelerometer assessment of ecologic gait and activity 
• MR imaging  
 

13 
 
In the control group, additional evaluations will be performed at 18 months (same as 6 month visit) 
and 24 months (same as 12 month visit). 
 
Neurocognitive Battery: The tests performed in the neurocognitive battery are: Montreal 
Cognitive Assessment (MOCA), Trail Making Test (TMT), Phonemic Fluency (Controlled Oral 
Word Association Test), Semantic Fluency (Animal Naming), Digit Symbol Coding from the 
Wechsler Adult Intelligence Scale, Third Edition, Hopkins Verbal Learning Test, Center for the 
Epidemiological Studies-Depression Scale, Neuropsychiatric Inventory, Questionnaire Version 
(NPI-Q), Mini Mental Status Exam. These tests are well standardized in the literature and can be 
administered by study coordinators after training from a clinical neuropsychologist. The test 
battery has been selected for tests sensitive to attentional, executive, and memory impairments 
particularly affected by subcortical vascular disease 5. 
 
MR imaging: Sequences performed will include FLAIR, volumetric T1, GRE, diffusion tensor 
imaging (DTI) and arterial spin labeled (ASL). The total table acquisition time will be 18 
minutes.  
 
Measurement of Volumetric MRI Assessment:  
 
All participants will undergo a 1.5-Tesla MRI scanning on the same Magnetom scanner. 
(Siemens, Erlangen, Germany). The protocol will include the following whole brain scans: 3D 
T1 MPRAGE imaging (TR/TE/TI 2250/3.68/850 ms; flip angle15º;  
voxel size 1.0 × 1.0 × 1.0 mm); FLAIR pulse sequences (TR/TE/TI 9000/84/2200 ms; voxel size 
1.0 × 1.2 × 5.0 mm, interslice gap 1 mm); DTI (TR/TE 10100/93 ms; voxel size 
2.5 × 2.5 × 2.5 mm; 4 unweighted scans, 30 diffusion weighted scans with b-value 900 s/mm²). 
The complete protocol is estimated to take 35 min. 
 
White matter signal hyperintensities in both supra and infratentorial regions on FLAIR scans, 
which were not, or only faintly, hypo-intense on T1 weighted images, will be considered WML, 
except for gliosis surrounding infarcts. WML will be manually segmented on FLAIR images by 
two trained raters. Total WML volume will be calculated by summing the segmented areas 
multiplied by slice thickness. Lacunar infarcts were defined as hypo-intense areas with a diameter 
> 2 mm and < 15 mm with low signal intensity on T1 and FLAIR, ruling out enlarged perivascular 
spaces and infraputaminal pseudolacunes 6. All imaging analyses will be performed by raters 
blinded to clinical information.  
 
Normalization parameters to the ICBM152 linear template (as provided with SPM5; Wellcome 
Department of Cognitive Neurology, University College London, UK) and gray (GM) and white 
matter (WM) tissue and cerebrospinal fluid (CSF) probability maps will be computed by using 
SPM5 unified segmentation routines on the T1 MPRAGE images 7[. Total GM, WM and CSF 
volumes will be calculated by summing all voxel volumes that had a p > 0.5 for belonging to the 
tissue class. Total brain volume (TBV) will be taken  as the sum of total GM and WM. Intracranial 
volume (ICV) is a summation of all tissue classes, i.e. total GM, total WM and CSF volume. To 
normalize for head size, TBV will be expressed as percentage of total ICV. 
 
Co-registration parameters of the FLAIR image to the T1 image will be computed (SPM5 mutual 
information co-registration) and used to bring both the FLAIR and WML segmentation images 
into the subject's (anatomical) reference frame. Transformed images will be visually checked for 

14 
 
co-registration errors. Subsequently, the WML segmentations will be resampled to and combined 
with the white matter maps to yield to a WML map (the intersection of WML and white matter) 
and NAWM map (the complement of WML in white matter) in the T1 reference space. 
 
Diffusion Tensor Imaging Volumetric Analysis 
 
The diffusion weighted images of each subject will be realigned on the unweighted image using 
mutual information based co registration routines from SPM5. Then, the diffusion tensor  and its 
eigenvalues were computed using an SPM5 add-on (http://sourceforge.net/projects/spmtools)8. 
Unphysical spurious negative eigenvalues of the diffusion tensor will be set to zero, after which 
the tensor derivatives the MD and FA will be calculated_ENREF_899 . The mean unweighted 
image will be used to compute the co-registration parameters to the anatomical reference T1 image 
(SPM5 mutual information co-registration), which will then be applied to all diffusion weighted 
images and derivates. All images will be visually checked for motion artifacts and co registration 
errors. The mean MD and FA will be calculated in both the WML and NAWM. 
 
Measurement of Cerebral Atrophy 
 
Generalized brain atrophy will be scored on T1-weighted images. Cortical atrophy will be rated 
on a semiquantitative scale (range 0–15) using reference scans. Subcortical atrophy is measured 
as the ventricle : brain ratio (range 0.21–0.45) 10. Estimates of total brain atrophy will be computed 
primarily from T1-weighted images, bicaudate ratios will be derived from axially acquired images 
as an estimate of total brain atrophy following established protocols. To derive the bicaudate ratio, 
the axial slice on which the caudate nuclei produced the greatest amount of indentation on the 
lateral ventricles will be identified and the distance between the 2 caudate apices will be measured 
in millimeters. This value is divided by the maximum width of the skull at the same level as the 
caudate measurement. Using this approach, enlarged ventricles increase the distance between the 
2 caudate nuclei, resulting in a higher bicaudate ratio. Therefore, a larger value indicates a greater 
degree of atrophy. Bicaudate ratio measurements will be made by 2 experienced raters. Interrater 
reliability will also be computed 11. 
 
C.11. Measures to Avoid and Minimize Bias 
 
Study design considerations 
 
Including a sham device in this study is not a practicable option. Sham inflation to very low levels 
of pressure would be easily perceived as sham rather than genuine treatment by these older subjects 
who have substantial experience with blood pressure measurement. Accordingly, low pressure 
inflations would not protect the blind. Sham inflation to moderate levels of pressure would induce 
partial limb ischemia and potentially contaminate the control group with a partially active 
intervention. In addition, the outcome measures in this trial are robust against bias. The primary 
trial endpoint, tolerability and adherence to treatment in the intervention arms, does not draw upon 
the control group at all. The MR imaging measures of white matter injury progression, ascertained 
by automated analysis and blinded readers, are not subject to bias. To protect against bias in 
ascertainment of the recurrent stroke secondary endpoint, study design includes a) adjudication of 
potential endpoint stroke events by 2 independent blinded neurologists (preventing rater bias), and 
b) administration of the Questionnaire to Verify Stroke Free Status at each follow-up visit, to 
trigger endpoint evaluations (preventing ascertainment bias).   
 

15 
 
C.12. Blinding 
 
C.12.1 Clinical  
 
The neurocognitive battery and other clinical assessments, including imaging interpretation will 
be performed by individuals blinded to the treatment allocation of all the subjects to reduce 
investigator bias. All neurological examinations will be performed by a board-certified 
neurologist. NIHSS and mRs must be performed by certified study personnel 
 
C.12.2. Imaging 
 
The MR imaging measures of white matter injury progression will be ascertained by automated 
analysis and blinded readers. 
 
C.13. Adverse Events  
 
Serious adverse events (SAEs) will be identified at every scheduled follow-up point by study site 
investigators and study nurses. A serious adverse event is one that is fatal or life-threatening, is 
permanently or substantially disabling, requires or prolongs hospitalization, or is a congenital 
anomaly (Code of Federal Regulations, Title 21, Chapter ID, Part 312.32), SAEs will be reported 
to the IRB according to SAE reporting policy. All SAEs should be reported to the REM PROTECT 
Principal Investigator and the device manufacturer, CellAegis Devices, by telephone, fax, or email 
within 24 hours of detection.  
 
C. 14. Safety Monitoring 
C.14.1. Data and Safety Monitoring Board 
 
To ensure that appropriate ethical consideration is given to the welfare of the patients enrolled in 
the study, a Data and Safety Monitoring Board (DSMB) will oversee the trial. The DSMB will 
review the incidences and circumstances of adverse events that occur during the course of the trial. 
Formal interim analysis will occur at the half way -point, after enrolled patients have completed 
50% of patient months of follow up. If the incidence of recurrent stroke or all serious adverse 
events is higher in the combined device arm than the control arm the study will be placed on hold. 
The DSMB will conduct a detailed analysis of the safety data. The DSMB may recommend making 
changes it deems necessary in the interests of the safety or well-being of the study subjects, or 
suspending or stopping the study. Final determination of a formal stopping rule will be the 
prerogative of the appointed DSMB.  
 
The members of the DSMB are: 
 
Nerses Sanossian, MD, Stroke Neurologist, University of Southern California 
Amytis Towfighi, MD, Stroke Neurologist, Rancho Los Amigos National Rehabilitation Center 
 
C. 14.2. Statistical Design and Analysis Plan 
 
The demographic and baseline clinical characteristics of the study population will be delineated 
with standard descriptive statistics. Categorical variables describing the clinical history, 
examination findings, and initial treatment will be summarized by frequencies. Continuous 
variables such as vital signs, laboratory results, and time variables that follow normal distribution 

16 
 
will be characterized by means, standard deviations, and 95% confidence intervals (CI). Ordinal 
and non-normally distributed variables (such as the NIHSS) will be characterized by medians and 
interquartile ranges. RIPC and control patients will be compared to delineate covariate balance. 
Wilcoxon Rank-Sum tests will be used for continuous or ordinal variables; Fisher’s exact tests and 
chi-square tests will be used for grouped or nominal categorical variables. Comparisons of changes 
across time (i.e. base to one year) within and between groups will be made using repeated measure 
analysis variance methods or the non-parametric analog.  
 
C. 14.3. Selection and Analysis of Endpoints 
 
Feasibility: Because the primary aim of this trial is assessing feasibility and tolerability, the 
primary endpoints are descriptive statistics describing the implementation of the RPreC procedure, 
including behavioral adherence to treatment, physiologic attainment of limb ischemia, and patient 
self-reported comfort-discomfort during treatment. The simplicity of these endpoints reduces the 
likelihood of problems in the analysis and interpretation of these endpoints. The procedure will be 
considered adequately feasible if adherence and physiologic targets are attained in 75% or more 
of cases. At this early stage of development, observations and lessons from individual cases may 
warrant procedural protocol changes to optimize the intervention. Such flexible, developmental 
iterations of the intervention will be closely discussed with, and supervised by, the study DSMB. 
 
Safety: The lead safety endpoint will be all serious adverse events. Secondary safety endpoints 
will be deep and superficial vein thrombosis and all cause mortality.  
 
Efficacy: The lead efficacy endpoint will be volumetric progression of white matter ischemic 
injury on magnetic resonance imaging (biomarker efficacy). The primary MRI endpoint will be 
the proportion of patients with increase in total white matter hyperintensity volume (as percent of 
total brain volume) above 1.0%. (This value represents the threshold for the upper quintile of 
progression in the SCOPE trial. Proportion of patients with progression in the upper quintile was 
the most sensitive MR endpoint analyzed in the SCOPE substudy.) Additional MRI endpoints 
analyzed will include mean progression total white matter hyperintensity, mean and quintile 
progression in deep white matter hyperintensity, progression in total brain atrophy, and 
progression in DTI anisotropy. The MR imaging measures of white matter injury progression, 
ascertained by automated analysis and blinded readers, are not subject to bias. 
 
Additional efficacy endpoints explored will include accelerometer assessment of gait quantity 
and quality in real-world activity; z scores on individual tests and summed performance on the 
cognitive battery, and incident ischemic stroke, transient ischemic attack, hemorrhagic stroke, 
myocardial infarction, and cardiovascular death. To protect against bias in ascertainment of the 
recurrent stroke secondary endpoint, analysis to include a) adjudication of potential endpoint 
stroke events by 2 independent blinded neurologists (preventing rater bias), and b) administration 
of the Questionnaire to Verify Stroke Free Status at each follow-up visit, to trigger endpoint 
evaluations (preventing ascertainment bias).   
 
C.14.4. Sample Size Calculations 
 
Subject size is typical sample size for a feasibility study with a device. We are looking at 
adherence in order to plan a larger phase II/III successor trial.  
 
 

17 
 
 
 
Sample Size Justification 
 
The primary feasibility and study endpoint is RPreC adherence at 12 months. As we do not expect 
clinically important differences in adherence among the three groups, it may be possible to 
combine two or all three groups.   In this study, we also wish to test the null hypothesis that the 
true adherence is at least 75%. The table below gives the lower 90% or 95% confidence bound for 
90%, 95% or 100% observed adherence as a function of sample size and the corresponding 
statistical power for testing the null hypothesis that the true population adherence is 75% versus 
the one sided alternative of greater than 75%. The current study is not necessarily sufficiently 
powered for any of the safety or efficacy outcomes.  Therefore this is a pilot study in terms of 
safety and efficacy.  
 
 
  Lower 90% or 95% one sided confidence bound for true adherence 
 
adherence=90%  
adherence=95%  
adherence=100%  
                N 
90% 
confidence 
95% 
confidence 
90% 
confidence 
95% 
confidence 
90% confidence 
95% confidence 
                 20 
75.5% 
71.8% 
81.9% 
78.5% 
89.1% 
86.1% 
40 
81.0% 
78.5% 
87.2% 
85.1% 
94.4% 
92.8% 
60 
83.1% 
81.2% 
89.2% 
87.6% 
96.2% 
95.1% 
 
 
 
 
 
 
 
 Power for one sided test against null hypothesis of 75% vs > 75% 
 
adherence=90%  
adherence=95%  
adherence=100%  
N 
alpha=0.10 
alpha=0.05 
alpha=0.10 
alpha=0.05 
alpha=0.10 
alpha=0.05 
20 
0.677 
0.392 
0.925 
0.736 
>0.99 
>0.99 
40 
0.901 
0.794 
0.997 
0.986 
>0.99 
>0.99 
60 
0.966 
0.927 
1.000 
0.999 
>0.99 
>0.99 
 
 
 
C.15. Risk Assessment 
 
C.15.1. Formal risk analysis with regard to anticipated risk associated with the device is provided 
below as per IDE 130167.  Risks have been minimized or eliminated through appropriate design 
control and preclinical testing and bench testing of the device.  
The risks associated with the autoRIC are consistent with those of a standard automatic blood 
pressure cuff, including local bruising, abrasion, and pain at the site of the cuff.  Although 
extremely unlikely to occur, in the case of a serious device failure, hypothetical harms to the patient 
could include nerve or bone damage.   
 
As presented in Section 1.5 (IDE 130167), previous investigations have reported minimal to no 
safety implications associated with RIC. In clinical studies where the benefit of RIC was not 
statistically significant there was no compromise to patient safety.  Although the RIC protocol was 
performed manually in the investigations reported in the literature review, the autoRIC was 
verified to meet the applicable requirements of standard automated blood pressure cuffs and the 
performance validation testing conducted on the autoRIC ensures that it performs as intended.  As 

18 
 
such, the same performance results can be expected when the RIC protocol is automated by the 
autoRIC.   
 
C.15.2. Risks associated with MRI: 
 
The MRI scanner does not involve harmful ionizing radiation and is generally well-tolerated. 
There are no known harmful side-effects associated with temporary exposure to the strong 
magnetic field used by MRI scanners. There are no known long term risks or complications of 
MRI. However, there are important safety concerns to consider before performing or undergoing 
an MRI scan: 
 
1. The magnet may cause pacemakers, artificial limbs, and other implanted medical devices 
that contain metal to malfunction or heat up during the exam. 
2. Any loose metal object may cause damage or injury if it gets pulled toward the magnet. 
3. Dyes from tattoos or tattooed eyeliner can cause skin or eye irritation. 
4. Medication patches can cause a skin burn. 
5. The wire leads used to monitor an electrocardiogram (ECG) trace or respiration during a 
scan must be placed carefully to avoid causing a skin burn. 
6. Prolonged exposure to radio waves during the scan could lead to slight warming of the 
body. 
 
C.15.3. Other anticipated risks: 
 
Possible complications may occur during the procedure. The complications include but are not 
limited to, deep venous thrombosis or lymphatic occlusion, petechiae development, skin rash or 
sensitivity to the cuff, claustrophobia or nerve, bone, or muscle injury. As such, the risk mitigation 
policy will include, but is not limited to, periodic visual inspection of skin in arms, motor and 
sensory examinations of the hand to be performed at all office visits.