Coach Pilot Study: Assessing Cognitive Function and Related Small Vessel Disease Markers After Intracerebral Hemorrhage; a Pilot Study
Conditions: Cerebral Amyloid Angiopathy, Intracerebral Hemorrhage, Hypertensive Hemorrhage, Intracranial, Cognitive Decline
Sponsor: Leiden University Medical Center

RESEARCH PROTOCOL 
 
 
COACH-pilot study 
COgnition After intraCerebral Hemorrhage 
 
Full title:  
Assessing cognitive function and related small vessel 
disease markers after intracerebral hemorrhage;  
a pilot study. 
 
 
 
 
 
 
 
 
 
 
 
Onderzoeksprotocol 
 
23-02-2021 
Versie 4 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
2 
 
 
PROTOCOL TITLE 
Assessing cognitive function and related small vessel disease markers 
after intracerebral hemorrhage; a pilot study. 
 
 
 
 
 
 
 
Protocol ID  
NL74864.058.20 
Short title  
COACH-pilot Cognition After intraCerebral Hemorrhage 
Version  
3 
Date  
21-10-2020  
Coordinating investigator/project 
leader 
Prof. Dr. M.J.H. Wermer  
Department of Neurology LUMC  
Principal investigator(s) (in 
Dutch: hoofdonderzoeker/ 
uitvoerder) 
Drs. E.S. van Etten;  
Department of Neurology LUMC  
Prof. Dr. Ir. M.J.P. van Osch;  
Department of Radiology LUMC  
Dr. G.M. Terwindt;  
Department of Neurology LUMC  
Sponsor (in Dutch: 
verrichter/opdrachtgever) 
Leiden University Medical Center  
Albinusdreef 2 
2333 ZA Leiden  
Subsidising party  
The Dutch Heart Foundation and the Netherlands 
Organisation for Scientific Research (NWO), as part of 
their joint strategic research programme: "Earlier 
recognition of cardiovascular diseases”. This project is 
partially financed by the PPP Allowance made available 
by Top Sector Life Sciences & Health to the Dutch Heart 
foundation to stimulate public-private partnerships. 
Independent expert  
Dr. E.H. Niks; Department of Neurology LUMC  

NL74864.058.20 
  
Version 4; 23-02-2021  
 
3 
 
 
PROTOCOL SIGNATURE SHEET 
 
 
 
 
Name  
Signature  
Date  
Head of Neurology Department  
Prof. Dr. J.J.G.M. Verschuuren  
 
 
 
Coordinating Investigator  
Prof dr. M.J.H. Wermer 
 
 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
4 
 
 
TABLE OF CONTENTS  
 
1. SUMMARY……………………………………………………………………………………… 6 
 
2. INTRODUCTION AND RATIONALE…………………………………………………………. 7 
3. OBJECTIVES…………………………………………………………………………………… 9 
4. STUDY DESIGN……………………………………………………………………………….. 10 
5. STUDY POPULATION…………………………...……………………………………………. 10 
 
 
5.1 Population……………………………………………………………………………. 10 
 
5.2 Inclusion criteria……………………………………………………………………… 10 
 
5.3 Exclusion criteria……………………………………………………………............ 10 
 
5.4 Sample size calculation…………………………………………………………….. 11 
6. METHODS………………………………………………………………………………………. 12 
 
6.1 Study parameters/endpoints……………………………………………………….. 12 
 
6.2 Study procedures……………………………………………………………………. 12 
 
6.3 Withdrawal of individual subjects……………………………………...…………… 15 
 
6.4 Replacement of individual subjects after withdrawal………..... ……….. ……….. 15 
7. SAFETY REPORTING……………………………………………………………................... 15  
             7.1 Section 10 WMO event………………………………………………………………15 
             7.2 AEs, SAEs, and SUSARs……………………………………………………………15 
             7.3 Unexpected findings…………………………………………………………………..16 
8. SATISTICAL ANALYSIS……………………………………………………………....………. 16 
9. ETHICAL CONSIDERATIONS………………………………………………………. ……….. 17 
 
9.1 Regulation statement………………………………………………………………... 17 
 
9.2 Recruitment and consent…………………………………………………………… 17 
 
9.3 Benefits and risks assessment, group relatedness…………………………….... 17 
 
9.4 Compensation for injury…………………………………………………………….. 19  
 
9.5 Incentives…………………………………………………………………………….. 19  
10. ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION………….. ……….. 19 
 
10.1 Handling and storage of data and documents………………………………….. 19  
 
10.2 Monitoring and Quality Assurance……………………………………………….. 20 
 
10.3 Amendments……………………………………………………………………….. 20  
 
10.4 Annual progress report……………………………………………………………..20   
 
10.5 End of study report…………………………………………………………………. 20 
 
10.6 Public disclosure and publication policy…………………………………………. 20 
11. REFERENCES………………………………………………………………………………… 21 
 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
5 
 
LIST OF ABBREVIATIONS AND RELEVANT DEFINITIONS  
 
 
Aβ Amyloid beta  
CAA Cerebral amyloid angiopathy  
cSAH Cortical subarachnoid hemorrhage  
CSF Cerebrospinal fluid  
DTI Diffusion tensor imaging  
HA Hypertensive arteriopathy 
ICH Intracerebral hemorrhage  
IQCODE Informant Questionnaire on Cognitive Decline in the Elderly 
MB microbleeds  
METC  Medical research ethics committee (MREC); in Dutch: medisch-ethische toetsingscommissie 
(METC) 
MRI Magnetic Resonance Imaging  
mRS Modified Rankin Scale  
NIHSS National Institutes of Health Stroke Scale 
ePVS Enlarged Perivascular spaces  
sCAA Sporadic cerebral amyloid angiopathy  
cSS Superficial Siderosis  
SVD Small vessel disease 
WMH White matter hyperintensities 
 
 
 
 
 
 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
6 
 
1. SUMMARY 
Rationale: Dementia is a major contributor of dependence and disability in the ageing population and 
is mainly caused by neurodegenerative and cerebrovascular disease. Vascular cognitive impairment 
(VCI) occurs in at least 10% of patients who recover from an intracerebral hemorrhage (ICH) and has 
a major impact on post ICH recovery. In the acute phase of ICH, cognitive impairment may be caused 
directly by the hemorrhage damaging the brain parenchyma. In the chronic phase, however, further 
cognitive decline is also prevalent.  
Cognitive decline after ICH might be caused by the underlying etiology of the ICH. The most frequent 
underlying small vessel diseases (SVD) that cause ICH are cerebral amyloid angiopathy (CAA) and 
hypertensive arteriopathy (HA). CAA and HA have their own radiological signatures of SVD markers 
which allow for in vivo tracking of disease progression using MRI. Although the initial clinical 
presentation these two types of SVD differs – CAA classically presents with a lobar ICH, whereas HA 
causes deep ICH – both groups of patients are at risk of developing dementia. However, it has 
recently been shown that patients with lobar ICH develop new onset dementia twice as often as 
patients with deep ICH. Whether underlying CAA pathology causes this increase, remains unclear. In 
addition, whether ICH accelerates the process of vascular damage and if cognitive decline can be 
predicted by certain disease markers is uncertain. Understanding the underlying mechanisms for 
cognitive decline after ICH helps to improve knowledge of prognosis and clinical management of 
patients who are recovering from ICH.   
Objectives: The overall aim of this pilot study is to investigate the development of MRI and CSF 
markers after CAA-related and HA-related ICH in relation to cognitive decline. The results from this 
pilot trial will be used to design a larger cohort study to investigate underlying mechanisms of 
cognitive decline after ICH. 
Study design: The study design is a prospective cohort study. 
Study population: The study population consists of 32 patients; 16 patients with CAA-related ICH 
and 16 patients with HA-related ICH who are 55 years or older.  
Methods: Data will be collected at four measuring points: at baseline (during hospital admission for 
the ICH or at the outpatients clinic within one month of presentation with an acute ICH), after three 
months, after six months and after 12 months. Premorbid cognitive functioning will be assessed with 
the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) to select participants 
without pre-existing cognitive impairment.  
At baseline, the premorbid functional status will be assessed with the modified Rankin Scale (mRS) 
and Barthell index. A 3Tesla MRI will be performed to assess the most likely underlying cause of the 
ICH (patients with either CAA or HA-related ICH will be included). Stroke severity will be assessed 
with the National Institutes of Health Stroke Scale (NIHSS) and a neurologic exam will be performed. 
Participants will undergo an extensive interview on life-style, vascular risk factors and medication, and  

NL74864.058.20 
  
Version 4; 23-02-2021  
 
7 
 
will undergo a blood withdrawal. Neuropsychological testing will be performed and questionnaires will 
be used for screening for depression, anxiety and psychopathology. In addition, participants will be 
asked to undergo a lumbar puncture to collect cerebrospinal fluid (CSF). 
After three months, neurological examination, and neuropsychological testing will be repeated. 
After six and 12 moths, the neurological examination, the 3 Tesla MRI and neuropsychological testing 
will be repeated. Additionally, participants will be asked for a lumbar puncture at these two time 
points. 
Main study parameters/endpoints: The main parameters are cognitive decline (according to the 
neuropsychological assessment) at 12 months. Secondary outcomes are burden of SVD markers on 
MRI and CSF markers at baseline, at six months and 12 months. 
Nature and extent of the burden and risk associated with participation, benefit and group 
relatedness: The risks of MRI are minimal (risk of everyday life), because there are no 
consequences to the health of the participant. Contra-indications will be carefully investigated per 
subject, burden will be kept at a minimum by using short protocols. There is no direct benefit for the 
patients except for more insight into the underlying pathophysiology of the hemorrhages related to 
their disease.  
Blood withdrawal and lumbar puncture are routine procedures at the Department of Neurology. 
Lumbar puncture will be performed by experienced physicians. We will use atraumatic spinal needles 
to reduce the risk of post-lumbar puncture headache.  
Patients will be informed extensively about the potential risks of these procedures, after which written 
informed consent will be obtained.  
 
2. INTRODUCTION AND RATIONALE 
Cognitive impairment after intracerebral hemorrhage  
Dementia is a serious public health problem in the ageing population and cerebrovascular disease is 
a major cause of cognitive decline. After a first stroke, at least 10% of patients without previous 
cognitive impairment will develop dementia.1 In a large observational cohort study, even one in three 
patients develop new onset dementia within five years after stroke.2 Even though intracerebral 
hemorrhage (ICH) and ischemic stroke can both cause vascular cognitive impairment (VCI), ICH has 
received far less scientific attention than ischemic stroke. Nevertheless, ICH is more strongly 
associated with new post-stroke dementia than other stroke subtypes.2 
Predicting outcome after ICH is challenging. Cognitive decline is believed to cause the greatest 
impact on quality of life after ICH.3 A certain degree of cognitive deficit in the acute phase of ICH is  

NL74864.058.20 
  
Version 4; 23-02-2021  
 
8 
 
likely a direct result of the hemorrhage damaging the brain parenchyma, although it also depends on 
co-existing neurodegenerative pathology, the hemorrhage volume, and the location of the 
hemorrhage. Even though these cognitive deficits might partly resolve as the hemorrhage resorbs 
over time, some of the ICH survivors will have progressive cognitive decline and therefore a poor 
long-term outcome.3 The ICH might trigger or boost underlying small vessel disease underlying this 
cognitive decline. 
Post-ICH cognitive decline might be caused by the underlying causes of ICH. The most important 
cause of primary ICH is small vessel disease (SVD).1 The two most common subtypes of SVD are 
hypertensive arteriopathy (HA) and sporadic cerebral amyloid angiopathy (CAA). HA results from 
hypertension-related damage predominantly affecting small perforating end-arteries in the basal 
ganglia, brain stem, deep white matter, and cerebellum. CAA is caused by β-amyloid deposition within 
the wall of cortical and leptomeningeal arteries causing pathology in the lobar regions of the brain.4 
Therefore, when HA leads to an ICH it is most likely located in the deep brain structures, whereas 
CAA typically causes lobar ICH.5  
The incidence of new-onset dementia after stroke has been addressed in a cohort of 218 ICH 
patients. In these ICH survivors without dementia at baseline, new-onset dementia occurred with an 
incidence of 14.2% at 1 year and 28.3% at 4 years of follow up. Interestingly, this incidence was twice 
as high in patients with lobar ICH (23.4% at one year follow-up) than for patients with non-lobar ICH 
(9.2% at one year follow-up). This finding is in line with previous studies linking CAA to cognitive 
impairment.6  
MRI markers and cognitive impairment  
Underlying SVD-related pathology can be identified using MRI. Even though MRI does not show the 
entire spectrum of the underlying SVD pathology, it has improved our understanding of SVD 
pathology extensively in the recent years.7 MRI markers associated with CAA often are different or 
have a different distribution compared with MRI markers associated with HA.8 Deep cerebral 
microbleeds (MB’s), white matter hyperintensity (WMH), and MRI visible enlarged perivascular spaces 
(ePVS) located in the area of the basal ganglia are associated with HA.9 Markers associated with 
CAA include lobar MB’s, WMH, ePVS in the subcortical white matter, cortical subarachnoid 
hemorrhage (cSAH), intragyral hemorrhages, microinfarcts, cortical thinning, and cortical superficial 
siderosis (cSS).4  
Severe WMH, lacunar infarcts, microinfarcts, have been associated with vascular cognitive 
impairment.10 The association between cognitive impairment and MB’s has also been well 
established,11 and recent studies have shown that cSS plays an important role in predicting 
progression of CAA.12, 13 Additionally, altered white matter integrity measured with diffusion tensor 
imaging (DTI) has been found in patients with mild cognitive impairment14  and CAA15 and might be a 
marker of cognitive decline in post-ICH patients.  

NL74864.058.20 
  
Version 4; 23-02-2021  
 
9 
 
As both HA and CAA are likely to progress over time, and therefore continue to damage the brain, it 
can be assumed that these two forms of SVD cause further cognitive deterioration after ICH and that 
this can be demonstrated by progression of the burden of MRI markers.   
Biomarkers in cerebrospinal fluid   
Although the implications of MRI markers in CAA and HA patients become increasingly clear, it is 
unknown in what way disease progression and changes in cerebrospinal fluid (CSF) show a 
correlation. In the hereditary form of CAA, decreasing CSF levels of Aβ occur before patients develop 
an ICH, implicating vascular deposition of Aβ species as early steps in CAA pathogenesis.16 Whether 
they have a predictive value, however, for cognitive decline after ICH remains unclear.  
Potential risk factors that might affect cognitive decline after ICH  
Factors like hyperglycemia, obesity, insulin resistance, and hypertension cause microvascular 
disfunction and are therefore associated with cognitive impairment.17 In order to investigate the effect 
of SVD on cognition it is important to assess these risk factors, as well as medication use. 
Implications on clinical practice  
Currently no therapies to prevent or slow down cognitive impairment after stroke exist. However, 
understanding the underlying cause and the natural disease course might help physicians to inform 
patients and screen for cognitive decline in patients who are at risk. Furthermore, identifying markers 
that correlate with cognitive decline might be important for future therapeutic trials. The results of this 
pilot study will be used to power a larger cohort study to investigate underlying mechanisms of 
cognitive decline after ICH and the differences between non-CAA and CAA related pathology. We will 
learn about the prevalence of cognitive decline, the differences between markers and their 
association with cognitive decline and the optimal time points for MRI (6 or 12 months) to assess the 
potential of creating a prediction model of the SVD markers and cognitive decline.   
Overall aim: The overall aim is to study cognitive decline in patients who recover from ICH and the 
relation with SVD markers. The results will be used to design a larger cohort study.   
 
3. OBJECTIVES 
1. To investigate the proportion of patients with new-onset dementia after HA-related ICH and CAA-
related ICH by performing serial follow-up with neuropsychological testing.  
2. To investigate MRI markers for SVD disease at baseline and their progression during follow-up and 
study if and how these markers correlate with cognitive decline after HA-related ICH versus CAA-
related ICH.  
3. To assess CSF markers at baseline and progression during follow-up and study if and how CSF 
markers correlate with cognitive decline after HA-related ICH versus CAA-related ICH.  
4. To store blood and CSF of CAA and HA patients for biobanking purposes and future research. 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
10 
 
The results from this pilot study will be used to design a larger cohort study to investigate underlying 
mechanisms of cognitive decline after ICH. 
The cognitive decline and influencing factors ICH patients will be (whenever appropriate and 
dependent on the particular research question) compared with data from other research projects in 
the LUMC like the hereditary form of CAA (HCHWA-D, n=75), sporadic CAA (n=50), Alzheimer’s 
disease, and Huntington’s disease or available data on healthy controls. 
 
4. STUDY DESIGN 
The study design for this pilot study is a prospective cohort study. 
 
5. STUDY POPULATION 
5.1 Population 
The study population are patients with ICH that have no family history of hereditary forms of ICH such 
as hereditary CAA (HCHWA-D) and no cognitive impairment before the ICH. Patients will be aged ≥ 
55y, since the radiological Boston criteria for CAA-related ICH only include patients ≥ 55y.18  
5.2 Inclusion criteria 
ICH patients: 
1. Age ≥ 55y 
2. Ability and willingness to provide written informed consent.  
3. Supratentorial ICH with CAAa or HAb as the most likely cause.  
a CAA-related ICH is defined as an ICH that meets the criteria for definite or probable CAA according 
to the Modified Boston Criteria (appendix A)  
b HA-related ICH is defined as ICH located in the basal ganglia, thalamus, or the deep white matter 
and the presence of hypertension defined as: on treatment for hypertension, or known with high 
blood pressure (two measurements SBP >140 or DBP >90 mmHg) but not treated for hypertension. 
5.3 Exclusion criteria 
1. Age < 55y 
2. Unable to provide informed consent. 
3. Pre-existing cognitive impairment assessed with the Informant Questionnaire on Cognitive Decline 
in the Elderly (IQCODE); scores between 53 - 63 reflect pre-existing cognitive  mpairment.19 
 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
11 
 
4. Contra indications, such as: 
Contra-indications for 3T MRI. Examples of possible contra-indications are: 
- 
Claustrophobia 
- 
Pacemakers and defibrillators 
- 
Nerve stimulators 
- 
Intracranial clips 
- 
Intra-orbital or intraocular metallic fragments 
- 
Cochlear implants 
- 
Ferromagnetic implants 
- 
Hydrocephalus pump 
- 
Intra-uterine device 
- 
Permanent make-up 
- 
Tattoos above the shoulders 
- 
Reduced kidney function (estimated GFR < 30 ml/min/1,73m2; or nephrogenic systemic 
fibrosis / nephrogenic fibrosing nephropathy (NSF/NFD)) 
- 
Known prior allergic reaction to gadolinium contrast or one of the constituents of 
its solution for administration 
Contraindications for lumbar puncture: 
- 
Intracranial tumor 
- 
Compressio medullae 
- 
Signs and symptoms of increased intracranial pressure 
- 
Local infections of the skin 
- 
A coagulopathy including use of anti-coagulant drugs (INR ≥ 1.8) or 
thrombocytopenia (<40) 
Use of acetylsalicylic acid, NSAIDs, COX2 inhibitors or prophylactic low-molecular-weight heparin are 
no contraindications for lumbar puncture,  
5.4 Sample size calculations  
 For this pilot study, we require 32 participants (16 CAA-related ICH and 16 HT-related ICH). This 
sample size is considered to be sufficient to study the feasibility of the study procedures. Furthermore, 
the results of a pilot study with this sample size should provide sufficient data that are needed to 
determine a sample size of a future, larger cohort study. 
 
 
 
 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
12 
 
6. METHODS 
6.1 Study parameters/endpoints 
Cognitive functioning 
The neuropsychological assessment will consist of a battery of tests that measure different cognitive 
domains. Premorbid cognitive functioning will be assessed with the Informant Questionnaire on 
Cognitive Decline in the Elderly (IQCODE). Cognitive functioning will be tested using a Mini-Mental 
State Examination (MMSE), a Montreal Cognitive Assessment (MOCA), a Frontal Assessment Battery 
(FAB), Digit Span Test (DST), RAVLT-15 words test, Stroop test, Trail making test, the Hospital 
Anxiety and Depression Scale (HADS), the Center for Epidemiologic Studies Depression Scale (CES-
D), the Neuropsychiatric Inventory Questionnaire (NPI-Q), the Starkstein Apathy Scale (SAS) and the 
Prikkelbaarheidsschaal (PS). Cognitive impairment was defined as a score ≤ 1.5 standard deviation 
below the general population mean in one or more cognitive domains.  
MRI markers 
The presence and number of MBs, cSS, WMH, cSAH, ePVS, microinfarcts, intragyral hemorrhages, 
cortical atrophy and other new and known small vessel biomarkers will be assessed on 3T and scored 
according to the STRIVE criteria.20 White matter integrity will be assessed using quantitative MR 
measurements and perfusion will be assessed.  
Biomarkers in blood and CSF 
Blood samples will be analyzed for coagulation profiles, cholesterol levels, APOE status, inflammation 
profile and hormone levels. In addition, extra blood will be stored in the LUMC Biobank sCAA 
Neurological Diseases for future biomarker studies. Concentrations of Aβ40, Aβ42, t-tau, and p-
tau181 will be measured in CSF and other biomarkers that may be identified in the future. 
Other study parameters 
Further parameters of this study will include demographic data, current medical conditions, vascular 
risk factors (including smoking, alcohol use, drugs, physical exercise, sleep, hypertension, 
hypercholesterolemia, diabetes mellitus, family history and medication; in women also information on 
female medical history such as number of pregnancies, menstruation cycle and menopause will be 
retrieved), neurologic history (including previous ischemic or hemorrhagic stroke), BMI, and blood 
pressure.  
 
 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
13 
 
6.2 Study procedures  
Data will be collected at four measuring points: at baseline, after three months, after six months and 
after 12 months: 
- 
Baseline (during admission or at the outpatient clinic < 1 month after ICH onset) 
Intake, baseline characteristics and neurological examination will be performed, as well  
as neuropsychological testing, blood sample collection, and a 3Tesla MRI scan. 
Additionally participants will be asked to undergo a lumbar puncture.   
- 
Three months (regular follow-up visit) 
At three months during the routine outpatient clinic visit a neurological examination will be 
performed, as well as neuropsychological testing. 
- 
Six and twelve months (two additional study visits) 
At six and twelve months, neurological examination will be performed, as well as 
neuropsychological testing, and a 3Tesla MRI scan. Additionally, participants will be 
asked to undergo a lumbar puncture. 
• Intake, baseline characteristics and neurological examination  
During the baseline assessment the following demographic and base line characteristics will be 
recorded: date of birth, gender, current medical conditions, daily intake alcohol/drugs/caffeine, sleep, 
physical activity, smoking, medication, cardiovascular risk factors and neurologic history (including 
previous ischemic or hemorrhagic stroke and history of migraine). In women information about 
menstruation cycle, pregnancies and menopause will be recorded. BMI will be recorded. Contra-
indications for MRI will be checked. A standard neurological examination will be performed.  
• Neuropsychological testing 
As mentioned in 6.1, cognitive function will be tested using a Mini-Mental State Examination (MMSE), 
a Montreal Cognitive Assessment (MOCA), a Frontal Assessment Battery (FAB), Digit Span Test 
(DST), RAVLT-15 words test, Stroop test, Trail making test, the Hospital Anxiety and Depression 
Scale (HADS), the Center for Epidemiologic Studies Depression Scale (CES-D), the Neuropsychiatric 
Inventory Questionnaire (NPI-Q), the Starkstein Apathy Scale (SAS) and the Prikkelbaarheidsschaal 
(PS). 
• 3Tesla MRI 
MRI is a non-invasive method, which is able to detect abnormalities in the brain with a high resolution. 
MRI will be performed on a 3Tesla MR system. MR scanning is harmless to the health of the 
participant, for the scans in this protocol no contrast agents will be used. Scans are made by a 
certified MRI operator, who will accompany the participant and will check any MR contraindication. 
Scanning time will be kept to a maximum of 60 minutes for the complete protocol. 
 
 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
14 
 
The following 3Tesla scan protocol will be used: 
• Anatomical T1-weighted imaging 
• T2-weighted imaging 
• Fluid Attenuation Inversion Recovery (FLAIR)  
• A Susceptibility Weighted Imaging (SWI)  
• Diffusion-weighted imaging (DWI) 
• Diffusion tensor Imaging (DTI)  
• Arterial Spin Labeling (ASL) 
• Post-gadolinium 3DT1 and 3DFLAIR  
The 3T MRIs will be performed at inclusion and will be repeated at 6 months and after 1 year. The 
MRIs will be used to search for SVD markers (paragraph 6.1). 
3T MRI’s performed in the clinical setting can be used for study purposes with the participants 
permission. When a 3T is performed for research purposes only, participants generally will not receive 
the MRI results unless they want to know their personal outcome. In this case the results will be 
discussed with them by one of the neurologists/neurology residents. 
• Blood sample collection 
Blood samples (50 ml) will be analyzed for laboratory tests such as APOE status, cholesterol levels, 
inflammation and coagulation profile and hormone levels. 
If participants give permission for LUMC Biobank sCAA (part of the LUMC Biobank Neurological 
Diseases), an additional 50 ml blood will be drawn. These blood samples will be stored for future (yet 
unknown) biomarker analysis after approval of the participants. These blood samples will be handled 
confidentially and coded and will be stored in the LUMC Biobank sCAA Neurological Diseases. The 
regulations of the LUMC Biobank Neurological Diseases will be applicable to the LUMC Biobank 
sCAA under Neurological Diseases 
• CSF sample collection 
The earlier mentioned contraindications (see paragraph 5.3) to lumbar puncture will be checked. CSF 
will be sampled by lumbar puncture under standardized conditions by experienced physicians. The 
lumbar puncture will be performed in the interspaces between the lumbar vertebrae, at the L3-S1 
level, below the level where the spinal cord typically ends (L1) in adults. The lumbar puncture will be 
performed with sterile materials. The duration of the lumbar puncture is about 10 minutes. Atraumatic 
spinal needles will be used to minimize chances of post lumbar puncture headache. If a lumbar 
puncture fails with an atraumatic needle, a traumatic needle may be used. 
In total approximately 20 ml CSF will be collected. For routine parameters, cell count, protein and 
glucose, a maximum of 8ml will be collected. CSF for the proposed biomarker assays (paragraph 6.1) 
will be collected in polypropylene tubes, centrifuged, divided into 0.5 ml aliquots, and stored at -80oC 
until analysis. 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
15 
 
If participants give permission, additional CSF (12 ml) will be stored for future (yet unknown) 
biomarkers. By giving permission for CSF withdrawal and the LUMC Biobank sCAA Neurological 
Diseases, the subject gives permission for withdrawal and storing the CSF and coded medical 
information into the LUMC Biobank sCAA Neurological Diseases, which can be used for other 
scientific studies on biomarkers related to CAA without being notified. The regulations of the LUMC 
Biobank Neurological Diseases will be applicable to the LUMC Biobank sCAA Neurological Diseases. 
Three days after the visit, subjects will be contacted to check whether the lumbar puncture has 
resulted in any persistent complaints. Subject will not receive the CSF results because the lumbar 
puncture will be performed for research purposes only. 
6.3 Withdrawal of individual subjects  
Subjects can leave the study at any time for any reason if they wish to do so without any 
consequences. The investigator can decide to withdraw a subject from the study for urgent medical 
reasons. Decision to leave the study will not influence the diagnostic trajectory or treatment of patients 
in any way. In case a participant becomes mentally incompetent during the study period, the 
participant continues with the study unless he/she desires to end the participation or shows (verbal or 
non-verbal) resistance to the study procedures.   
6.4 Replacement of individual subjects after withdrawal  
Individual subjects who withdraw from the study or die before the end of the study will be replaced. 
The reason of withdrawal will be asked, but participants are also ensured that they don’t need to give 
a reason for ending their participation. Replaced individuals will not be excluded from the analysis.  
 
7. SAFETY REPORTING 
7.1 Section 10 WMO event 
In accordance to section 10, subsection 1, of the WMO, the investigator will inform the subjects and 
the reviewing accredited METC if anything occurs, on the basis of which it appears that the 
disadvantages of participation may be significantly greater than was foreseen in the research 
proposal. The study will be suspended pending further review by the accredited METC, except insofar 
as suspension would jeopardize the subjects’ health. The investigator will take care that all subjects 
are kept informed. 
7.2 AEs, SAEs, and SUSARs  
Adverse Events Adverse events are defined as any undesirable experience occurring to a subject 
during the study, whether or not considered related to the study procedures. All adverse events 
reported spontaneously by the subject or observed by the investigator or his staff will be recorded.  
 
- Serious Adverse Events A serious adverse event is any untoward medical occurrence or effect that  
- results in death;  

NL74864.058.20 
  
Version 4; 23-02-2021  
 
16 
 
- is life threatening (at the time of the event);  
- requires hospitalisation or prolongation of existing in patients’ hospitalisation;  
- results in persistent or significant disability or incapacity;  
- any other important medical event that did not result in any of the outcomes listed above due to 
medical or surgical intervention but could have been based upon appropriate judgement by the 
investigator.  
An elective hospital admission will not be considered as a serious adverse event. AEs and SAEs will 
be reported by the treating physician in the electronic medical patient file. The investigator will report 
all SAEs to the sponsor without undue delay after obtaining knowledge of the events.  
The sponsor will report the SAEs through the web portal ToetsingOnline to the accredited METC that 
approved the protocol, within 7 days of first knowledge for SAEs that result in death or are life 
threatening followed by a period of maximum of 8 days to complete the initial preliminary report. All 
other SAEs will be reported within a period of maximum 15 days after the sponsor has first knowledge 
of the serious adverse events.  
 
- Suspected Unexpected Serious Adverse Reactions Adverse reactions are all untoward and 
unintended responses to an investigational product related to any dose administered. 
Unexpected adverse reactions are SUSARs if the following three conditions are met: 
1. the event must be serious; 
2. there must be a certain degree of probability that the event is a harmful and an undesirable reaction 
to the study procedure 
3. the adverse reaction must be unexpected, that is to say, the nature and severity of the adverse 
reaction are not in agreement with the product information as recorded in: 
- Summary of Product Characteristics (SPC) for an authorised medicinal product; 
7.3 Unexpected findings  
In case of an unexpected findings, the participant will be informed. In the informed consent the 
participant is also asked for permission to share any unsuspected findings with his/her general 
practitioner. 
8. STATISTICAL ANALYSIS 
Descriptive statistics will be performed. New onset cognitive impairment and dementia will be 
determined (according to the MMSE scale) and compared between CAA-related and HA-related ICH. 
Prevalence of different biomarkers in CSF and MRI and their evolution over time will be assessed. 
Linear regression analysis will be used to examine associations of MRI and CSF markers primarily 
with the MMSE and secondarily with the other cognitive scores. Some MRI markers, such as MB’s 
count will be transferred logarithmically. Based on our power calculation (see references paragraph 
5.4) we expect that the number of participants will be sufficient for analyses of difference in cognitive 
decline between CAA-related ICH and HA-related ICH. This pilot study is, however, not powered to 
detect significant associations between cognitive decline, MRI markers and CSF markers. The 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
17 
 
evolution of MRI and CSF markers will, however, give enough insight to power a larger trial to 
investigate the underlying mechanisms of cognitive decline after ICH. In addition, we will assess 
whether levels of MRI and CSF markers change between 6 and 12 months after the ICH to decide 
which timepoint is most relevant for a larger study as in the subsequent study we aim to have one 
follow-up time point for a MRI and lumbar puncture.  
 
9. ETHICAL CONSIDERATIONS 
9.1 Regulation statement  
The study will be conducted according to the principles of the "Declaration of Helsinki" (as amended in 
Fortaleza, Brazil, October 2013) and in accordance with the Guideline for Good Clinical Practice 
(CPMP/ICH/135/95 - 17th July 1996). 
9.2 Recruitment and consent 
The protocol of this study will be submitted to the Medical Ethics Committee of the Leiden University 
Medical Center and the study will not commence before formal approval has been granted. 
Participants will be selected from our LUMC ICH population. This population consists of patients 
referred to our emergency department for ICH and are admitted to our clinic. Patients will be 
contacted by one of the neurologists, neurologic residents or research physicians. In addition, 
neurologists from other hospitals can send their patients who want to participate in our studyif they 
are < 1 month after ICH onset. The purpose of the study will be explained and the eligible participants 
will receive a letter with information about the study. The purpose and method of the study will be 
described in the information letter (see attachment ‘proefpersoneninformatie’). Participants who are 
not able to give informed consent will not be included in the study. All participants are free to 
discontinue the study at any time. Participation in this study will have no negative financial 
consequences for the patient, travel expenses will be compensated for. 
Written informed consent will be obtained for the (repeated) 3T MRI, venous puncture and lumbar 
puncture. Subjects will be asked for a written informed consent for future projects with blood and CSF 
stored for biobanking purposes. 
Investigations at the different time points can take place on a single day at each time point, depending 
on the preference of the patient. 
9.3 Benefits and risks assessment, group relatedness 
To learn more about the pathophysiology, progression and prognosis of cognitive decline after ICH, 
we need to investigate ICH patients over a long period of time. By investigating MRI markers, CSF 
markers and cognitive functioning we will obtain more insight on individuals at risk. Moreover, this 
study hopefully eventually leads to new targets for therapy and will give insight in the sample size 
needed for a larger study to investigate mechanisms behind cognitive decline after ICH. Patients will 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
18 
 
be informed extensively about the potential risks of the study procedures, after which written informed 
consent will be obtained. 
The potential risks of this study are limited. The risks of gadolinium enhanced 3Tesla MRI are 
minimal. Gadolinium enhanced 3T MRI is performed in patients with ICH in routine clinical practice as 
part of the workup to find an underlying cause such as a tumor or a macrovascular cause according to 
the guidelines of the American Heart Association (2015) and the European Stroke Organisation 
(2019). Deposits of gadolinium can remain in the brains of some patients who have undergone 4 or 
more MRI scans with gadolinium for a prolonged time after the last administration. Deposits of 
gadolinium have also been reported in skin and bone. The European Medicines Agency has 
concluded that here is  no evidence that gadolinium deposition in the brain has caused any harm to 
patients. A nephrogenic systemic fibrosis (NSF) has also been reported after gadolinium-based 
contrast agent administration. The most important risk factor for NSF is a severely reduced kidney 
function (eGFR < 30 ml/min/1.73m2). The type of gadolinium-based contrast agent is also determinant 
for the risk of NSF. Allergic reactions to gadolinium-based contrast agents have also been reported. 
Other potential risks include movement of ferromagnetic objects in the body. Some participants may 
feel claustrophobic in the restricted space of the MR scanner. 
The potential risks related to MRI will be minimized in the following manner: 
• Claustrophobia 
Claustrophobia from the MRI scan will be reduced by explaining the nature of the scanner in detail 
before enrolment. At all times, the subjects will be able to communicate with the researcher, so if 
claustrophobia becomes a problem the subject can request to be removed from the scanner. 
• Movement of ferromagnetic objects in the body 
A list of questions concerning risk factors of MRI must be filled in by the subject. Based on the 
answers the subject is or is not allowed to go into the scanner.  
• Gadolinium will be administered once, the administered dose of gadolinium will be kept as low as 
possible, and a macrocyclic gadolinium-based contrast agent (Gadoteraat (Dotarem 0,5 mmol/ml, 
Guerbet) will be used to maximize safety. After administering gadolinium participants will be under 
observation for at least 30 minutes to check on signs of an allergic reaction. Participants will be 
advised to avoid repeated gadolinium administering in the next 24hours and creatinine clearance will 
be checked for reduces kidney function.  
Blood withdrawal via venous puncture in the elbow has a very low rate of adverse events. The needle 
puncture may cause bruising and in very rare cases an infection of the skin or blood vessel may occur 
at the puncture site. 
A lumbar puncture is a minimal burdening to patients if the patient is in the right position and if the 
patient has a normal anatomy of the vertebrae. Usually, the lumbar puncture itself takes about 10 
minutes and patients stay in the hospital afterwards for about half an hour. The most frequently 
occurring complication of lumbar puncture is post-lumbar puncture headache. This complication is 
much rarer when atraumatic spinal needles are used. If post-lumbar puncture headache occurs, 
subjects should take bed rest, drink ample water, and may use paracetamol if required. If the post-

NL74864.058.20 
  
Version 4; 23-02-2021  
 
19 
 
lumbar puncture headache persists for more than a week, a blood patch may be considered which is 
usually effective in treating the headache.21, 22 Very rarely, infection such as meningitis or spinal 
abscess may occur. Patients will be contacted by phone three days after lumbar puncture to check 
whether the lumbar puncture has resulted in any persistent complaints. If there are complaints 
following the puncture, one of the neurologists will contact the patient to make sure adequate 
measures (e.g. a blood patch) are taken. 
The potential risks related to lumbar puncture will be minimized in the following manner: 
• Post-lumbar puncture headaches 
We will use atraumatic spinal needles and will take out the needle with the stylet reinserted. To further 
reduce the risk, we will advise the patients to drink ample water and drinks with caffeine. A 
prospective study to investigate possible predictors for postdural puncture headache revealed young 
age and low BMI as significant risk factors.23 Our study population will consist of middle-aged or older 
participants for the most part. 
• Risk of infection 
We will minimize the risk of infection by working under sterile conditions. 
There is no benefit for the patients except for more general insight into the underlying 
pathophysiology of the hemorrhages related to their disease. 
9.4 Compensation for injury  
Subjects are insured by the insurance of the LUMC. The LUMC has a liability insurance which is in 
accordance with article 7, subsection 6 of the WMO. The insurance covers an amount of € 650.000 
per participant, € 5.000.000 for the entire study, and € 7.500.000 per year for all studies from the 
same sponsor.  
9.5 Incentives 
All participants will be compensated for traveling costs. 
 
10. ADMINISTRATIVE ASPECTS AND PUBLICATION 
10.1 Handling and storage of data and documents  
All study data will be handled confidentially. All data will be coded. The investigator will retain the 
originals of all source documents generated at LUMC for a period of 2 years after the report of the 
study has been finalized, after which all study-related documents will be archived for 15 years. The 
handling of personal data complies with the EU General Data Protection Regulation and the Dutch 
Act on Implementation of the General Data Protection Regulation (in Dutch: Uitvoeringswet AVG, 
UAVG). The person responsible for the processing of personal data will be Prof. Wermer and drs. 
E.S. van Etten.. Blood products and CSF for future biomarker research will be stored with coded 
medical information into the LUMC Biobank under ‘Neurologische Ziekten’. Results of the 
Neuropsychological testing will be sent and stored in the digital CASTOR EDC database. CASTOR is 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
20 
 
compliant with 21 CFR Part 11, ICH E6 GCP, GDPR, and HIPAA. ISO27001 and ISO9001 certified. 
Informed consents will be stored at the Neurology department of the LUMC at K5-106.  
Participants may withdraw from this study at any time, without any consequences. This also accounts 
for the blood products and CSF, which will be destroyed after withdrawal. When measurements 
already have been performed, these data will still be used. 
10.2 Monitoring and Quality Assurance 
This study will be monitored by a research group-independent monitor. The monitor will visit the site 
at the end of the study and will assess informed consent procedures, protocol compliance / protocol 
violations, source document verification, reporting of (serious) adverse events in 1-10% of included 
patients. Available data management systems will be evaluated for privacy, security, completeness 
and back-ups. The monitor may visit the site on additional occasions, in case the investigators 
request to do so. For each monitoring visit, a written report will be made up, which will be stored in the 
trial master file. 
10.3 Amendments  
Amendments are changes made to the research after a favourable opinion by the accredited METC 
has been given. All amendments will be notified to the METC that gave a favourable opinion. 
10.4 Annual progress report  
The investigator will submit a summary of the progress of the trial to the accredited METC once a 
year. Information will be provided on the date of inclusion of the first subject, numbers of subjects 
included and numbers of subjects that have completed the trial, serious adverse events/serious 
adverse reactions, other problems, and amendments.  
10.5 End of study report 
The investigator will notify the accredited METC of the end of the study within a period of 8 weeks. 
The end of the study is defined as the last patient’s visit. The study will be terminated prematurely in 
case of safety problems. Also, the study will be terminated if it is temporarily suspended for reasons of 
subjects' safety and the accredited METC gives a negative decision after assessing the reasons that 
led to the temporary suspension. Within one year after the end of the study, the investigator will 
submit a final study report with the results of the study, including any publications/abstracts of the 
study, to the accredited METC. 
10.6 Public disclosure and publication policy 
Results of this study will be published in international peer-reviewed scientific journals and will be 
presented on (inter)national scientific conferences and meetings. This will be in accordance to the 
CCMO statement on publication policy. 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
21 
 
11. REFERENCES 
1. 
Moulin S, Labreuche J, Bombois S, et al. Dementia risk after spontaneous intracerebral 
haemorrhage: a prospective cohort study. The Lancet Neurology 2016;15:820-829. 
2. 
Pendlebury ST, Rothwell PM, Oxford Vascular S. Incidence and prevalence of dementia 
associated with transient ischaemic attack and stroke: analysis of the population-based Oxford 
Vascular Study. The Lancet Neurology 2019;18:248-258. 
3. 
Donnellan C, Werring D. Cognitive impairment before and after intracerebral haemorrhage: 
a systematic review. Neurological sciences : official journal of the Italian Neurological Society and of 
the Italian Society of Clinical Neurophysiology 2020;41:509-527. 
4. 
Charidimou A, Boulouis G, Gurol ME, et al. Emerging concepts in sporadic cerebral amyloid 
angiopathy. Brain 2017;140:1829-1850. 
5. 
Viswanathan A, Greenberg SM. Cerebral amyloid angiopathy in the elderly. Ann Neurol 
2011;70:871-880. 
6. 
Charidimou A, Gang Q, Werring DJ. Sporadic cerebral amyloid angiopathy revisited: recent 
insights into pathophysiology and clinical spectrum. Journal of neurology, neurosurgery, and 
psychiatry 2012;83:124-137. 
7. 
van Veluw SJ, Jouvent E, Charidimou A. Editorial: Cerebral Small Vessel Diseases: From 
Vessel Alterations to Cortical Parenchymal Injury. Frontiers in neurology 2020;11:92. 
8. 
Charidimou A, Boulouis G, Haley K, et al. White matter hyperintensity patterns in cerebral 
amyloid angiopathy and hypertensive arteriopathy. Neurology 2016;86:505-511. 
9. 
Charidimou A, Boulouis G, Pasi M, et al. MRI-visible perivascular spaces in cerebral amyloid 
angiopathy and hypertensive arteriopathy. Neurology 2017;88:1157-1164. 
10. 
Kalaria RN. The pathology and pathophysiology of vascular dementia. Neuropharmacology 
2018;134:226-239. 
11. 
Lei C, Lin S, Tao W, Hao Z, Liu M, Wu B. Association between cerebral microbleeds and 
cognitive function: a systematic review. J Neurol Neurosurg Psychiatry 2013;84:693-697. 
12. 
Charidimou A, Linn J, Vernooij MW, et al. Cortical superficial siderosis: detection and clinical 
significance in cerebral amyloid angiopathy and related conditions. Brain 2015;138:2126-2139. 
13. 
Moulin S, Casolla B, Kuchcinski G, et al. Cortical superficial siderosis. Neurology 
2018;91:e132-e138. 
14. 
Stebbins GT, Murphy CM. Diffusion tensor imaging in Alzheimer's disease and mild cognitive 
impairment. Behav Neurol 2009;21:39-49. 
15. 
van Veluw SJ, Reijmer YD, van der Kouwe AJ, et al. Histopathology of diffusion imaging 
abnormalities in cerebral amyloid angiopathy. Neurology 2019;92:e933-e943. 
16. 
van Etten ES, Verbeek MM, van der Grond J, et al. beta-Amyloid in CSF: Biomarker for 
preclinical cerebral amyloid angiopathy. Neurology 2017;88:169-176. 
17. 
van Sloten TT, Sedaghat S, Carnethon MR, Launer LJ, Stehouwer CDA. Cerebral microvascular 
complications of type 2 diabetes: stroke, cognitive dysfunction, and depression. Lancet Diabetes 
Endocrinol 2020. 
18. 
Linn J, Halpin A, Demaerel P, et al. Prevalence of superficial siderosis in patients with 
cerebral amyloid angiopathy. Neurology 2010;74:1346-1350. 
19. 
Jorm AF. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly 
(IQCODE): development and cross-validation. Psychol Med 1994;24:145-153. 
20. 
Wardlaw JM, Smith EE, Biessels GJ, et al. Neuroimaging standards for research into small 
vessel disease and its contribution to ageing and neurodegeneration. The Lancet Neurology 
2013;12:822-838. 
21. 
Oedit R, van Kooten F, Bakker SL, Dippel DW. Efficacy of the epidural blood patch for the 
treatment of post lumbar puncture headache BLOPP: a randomised, observer-blind, controlled 
clinical trial [ISRCTN 71598245]. BMC Neurol 2005;5:12. 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
22 
 
22. 
van Kooten F, Oedit R, Bakker SL, Dippel DW. Epidural blood patch in post dural puncture 
headache: a randomised, observer-blind, controlled clinical trial. J Neurol Neurosurg Psychiatry 
2008;79:553-558. 
23. 
van Oosterhout WPJ, van der Plas AA, van Zwet EW, Zielman R, Ferrari MD, Terwindt GM. 
Postdural puncture headache in migraineurs and nonheadache subjects: A prospective study. 
Neurology 2013;80:941-948. 
  
 
 
 
 
 

NL74864.058.20 
  
Version 4; 23-02-2021  
 
23 
 
APPENDIX A