Phase 2 Study of Allogeneic Umbilical Cord Blood Infusion for Adults With Ischemic Stroke - CoBIS 2
Phase: PHASE2
Conditions: Stroke, Stroke, Acute, Brain Injury, Acute
Sponsor: Joanne Kurtzberg, MD

Phase 2 Study of Allogeneic Umbilical Cord Blood Infusion for Adults with Ischemic Stroke – CoBIS 2 
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Phase 2 Study of Allogeneic Umbilical Cord Blood Infusion for Adults 
with Ischemic Stroke - CoBIS 2 
IND 16274 
NCT03004976 
 
Version Number: V.4.0 
19 Feb 2018 
Principal Investigator: 
 
Joanne Kurtzberg, MD 
Robertson Clinical and Translational Cell Therapy Program 
DTRI/Duke University 
Phone:  919-668-1100 
 
Co-Investigators: 
Daniel Laskowitz, MD 
Department of Neurology 
Duke University 
Phone: 919-687-4686 
 
Michael Frankel, MD 
Department of Neurology 
Emory University School of Medicine 
404-778-3444 
 
Elizabeth Shpall, MD 
The University of Texas 
MD Anderson Cancer Center 
713-745-2161 
 
Nandakumar Nagaraja, MD 
McKnight Brain Institute 
University of Florida Health 
352-273-5550 
John J. Volpi, MD 
Eddy Scurlock Stroke Center 
Houston Methodist Neurological Institute  
713-441-3951 
 
Daniel Vela Duarte, MD 
Department of Neurology 
University of Colorado 
720-848-8529  

Phase 2 Study of Allogeneic Umbilical Cord Blood Infusion for Adults with Ischemic Stroke – CoBIS 2 
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Samir Belagaje, MD 
Stroke Rehabilitation 
Marcus Stroke and Neuroscience 
Center 
404-778-3444 
 
 
 
 
 
 
 
 
 
 
 

Phase 2 Study of Allogeneic Umbilical Cord Blood Infusion for Adults with Ischemic Stroke – CoBIS 2 
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PROTOCOL SUMMARY 
Title: 
Phase 2 Study of Allogeneic Umbilical Cord Blood Infusion 
for Adults with Ischemic Stroke – CoBIS 2 
Summary: 
This is a multicenter, placebo controlled, randomized, 
double-blinded Phase 2 study in 100 subjects 18-90 years of 
age who have sustained a recent ischemic stroke. Potential 
subjects can be screened on the day of the primary stroke 
event, after confirmation of ischemic stroke, but neurological 
status must be confirmed within 24 hours prior to infusion. 
Consent may be obtained ≥ 24 hours following stroke onset 
(Day 1), but no later than 10 days after the index stroke 
event. Treatment with umbilical cord blood (UCB) cells or 
placebo will be administered intravenously as a single 
infusion as early as 3 days but no later than 10 days after the 
patient’s stroke. Administration of UCB cells or placebo 
diluent will only be done after confirmation of eligibility 
criteria. UCB units will be selected from an accredited U.S. 
public cord bank based on blood type and a targeted cell dose 
ranging between 0.5 to 5 x 107 total nucleated cell count 
(TNCC)/kg. Study patients will not receive 
immunosuppressive or myeloablative medications prior to 
infusion of the cord blood or placebo.  
All subjects, families and medical staff will be blinded to 
treatment arm. When a subject is randomized to study drug at 
a clinical site without a cord blood bank, the selected cord 
blood units (CBU) will be shipped frozen overnight to the 
site. Once selected and available on site, each CBU will be 
thawed, washed, tested, released and infused intravenously 
using common standard operating procedures (SOPs) at all 
sites. For subjects randomized to placebo, a diluent with the 
same appearance and odor as a CBU will be prepared.  
Patients will have magnetic resonance imaging (MRI) at 
baseline and will be assessed at 1, 3, 6, and 12 months for 
functional outcomes. All patients will receive standard of 
care therapy while enrolled in this study and all subjects will 
be strongly encouraged to participate in rehabilitative 
therapy. 
Objectives: 
 
Primary 
 
To determine, in a randomized, placebo controlled trial, the 
efficacy of a single intravenous (IV) infusion of unrelated 
donor UCB for improving functional outcomes in patients 
with ischemic stroke 

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Secondary objectives 
1. To describe the safety and tolerability of a single IV 
infusion of unrelated donor UCB in patients with 
ischemic stroke 
2. To evaluate the efficacy of a single IV infusion of 
unrelated donor UCB for improvement of neurological 
symptoms following ischemic stroke 
3. To evaluate the efficacy of a single IV infusion of 
unrelated donor UCB for improvement in quality of life 
and emotional and cognitive status in patients with 
ischemic stroke 
Exploratory objectives:   
The following may be pursued 
if adequate data are available: 
 
To determine whether biomarkers of brain inflammation, 
neuronal injury, and repair are differentially expressed as a 
function of UCB administration   
Endpoints 
 
Primary endpoints: 
 
The primary endpoint is the shift in modified Rankin Scale 
(mRS) from baseline to 3 months post infusion. 
 
 
Secondary endpoints: 
1. Safety and tolerability of donor UCB infusion in adults 
with ischemic stroke will be assessed by the following:  
a. Incidence and severity of infusion reactions 
b. Incidence and severity of product-related infections 
c. Evidence of alloimmunization via anti-HLA and 
anti-RBC antibodies and nonspecific markers of 
systemic inflammation (including erythrocyte 
sedimentation rate [ESR], C-reactive protein [CRP]) 
d. Incidence and severity of graft vs. host disease 
e. Incidence and severity of unexpected adverse events 
(AEs), by relation to study product 
f. Mortality 
2. Functional independence at 90 days defined as a 90-day 
mRS score of 0, 1, or 2 
3. mRS shift score at 30 and 180 days post infusion 
4. The National Institutes of Health Stroke Scale (NIHSS) 
score at 90 days 
5. The Barthel Index (BI) at 90 days 
6. The Stroke Impact Scale-16 at 90 days 

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7. The European Quality of Life (EQ-5D-3L) survey at 
90 days 
8. Patient Health Questionnaire Scale (PHQ-8) at 90 days 
9. Telephone Interview for Cognitive Status (TICS) total 
score at 30 days and 12 months 
10. Stroke Inventory Test Battery scores at 90 days 
 
Exploratory Endpoints 
Inflammatory cytokines and biomarkers of brain injury and 
repair (for example, S100 calcium-binding protein B 
[S100B], TNFα, IL 1β, IL-4 and IL-10, VEGF, BDNF, 
MMP9) in peripheral blood at baseline, within 6-24 hours 
after UCB infusion, and 90 days (Research Blood Samples) 
Population: 
The target population is 100 patients ages 18-90 years with 
recent, acute, cortical, hemispheric, ischemic stroke in the 
middle cerebral artery (MCA) distribution without a 
clinically significant midline shift as detected by MRI as a 
DWI abnormality. 
Eligible patients will have National Institutes of Health 
Stroke Scale (NIHSS) scores of 6-15 (R) and 6-18 (L) at the 
time of informed consent. Subjects with >4 point increase of 
NIHSS from time of consent (worsening of score) will not be 
eligible for infusion. 
Patients must have a platelet count >100,000/uL, hemoglobin 
>8gm/dL, absolute lymphocyte count (ALC) ≥ 1200 for 
African American patients and ≥1500 for all other racial-
ethnic groups, and white blood cells (WBC) >2,500/uL 
OR 
Historical pre-stroke value of ALC ≥ 1200 for African 
American and ≥1500 for all other racial-ethnic groups within 
6 months of stroke 
And a post stroke ALC value of ≥ 1000, platelet count 
>100,000/uL, hemoglobin >8gm/dL and WBC >2,500/uL. 
 
Patients who have received tissue plasminogen activator 
(tPA) or undergone endovascular reperfusion may be 
included in the study if they are otherwise eligible. 
Phase: 
2 

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Number of centers enrolling 
participants: 
 up to 6 
Description of Study Agent: 
ABO/Rh matched CBU(s) with a minimum of 
0.5 x 107 TNCC/kg based on the pre-cryopreservation TNCC  
Study Duration: 
Approximately 36 months:  20-24 months of accrual to enroll 
100 patients, plus 12 additional months to the last patient’s 
final follow-up assessment. 
Participant Duration: 
The duration of the study for the patient will be 12 months 
from the initial infusion. Patients will have a baseline MRI 
and will be assessed at 1, 3, 6, and 12 months for functional 
outcomes. 
 
 
 

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Summary of Amendment 19, February 2018 
The protocol was amended as follows: 
• Co-investigators: 
o Doctors Nagaraja, Vela Duarte and Belagaje from the University of Florida, 
University of Colorado, and Emory, respectively, have been added as co-
investigators 
• Protocol summary, population: 
o Revised “time of enrollment” to “time of informed consent” to add clarity 
surrounding the timing for the NIHSS used to confirm eligibility. 
o Revised language to clarify timing of screening and consent. 
o Revised language to clarify that subjects with >4-point increase of NIHSS score 
from time of consent will not be eligible for infusion. 
o Revised ALC language. 
• Section 2.5.2.6 Stroke Impact Scale-16 (SIS-16): 
o Time to administer SIS-16 was included. 
• Section 2.5.2.7 Telephone Interview for Cognitive Status (TICS) 
o Added guidance for administration of TICS with an aphasic patient. 
• Section 3.1 Study Design Overview and Duration: 
o Revised language to provide clarity surrounding the timing for the NIHSS to be 
used for confirming eligibility. 
• Figure 3: 
o Revised footnote to include additional detail and clarity surrounding the timing 
for screening and consent. 
• Section 3.2.2 Inclusion Criteria: 
o ALC language has been updated as described in the protocol summary revision 
above. 
o Revised NIHSS inclusion criteria #3 to clarify timing of assessment. 
o Revised NIHSS language to clarify that subjects with >4-point increase of NIHSS 
from time of consent will not be eligible for infusion. 
• Section 3.2.3.2 Prohibited Concomitant or Prior Therapies: 
o  #6 – revised to add clarity regarding timing. 
o #8 – revised to add clarity regarding timing. 
• Section 4.7 Care During Unexpected Events: 
o Revised language describing care during onset of a fever event so it reflects 
maximum temperature in degrees Celsius and Fahrenheit. 
o Included guidance on how to handle a fever on the day of infusion and that the 
infusion should be postponed if fever >38.1° C (100.5°F). If the temperature 
drops and patient stabilizes to 38.1° C (100.5°F) and remains no higher than this 
for 24 hours, then the infusion may proceed as planned. 
• Table 5: 
o Revised column header from “UCB or Placebo Infusion” to “Day of Infusion” 
o Added guidance regarding the timing for pre-medications on the day of infusion.  
o Footnote a – revised to add clarity surrounding the timing for screening and 
consent. 

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o Foot note b – revised wording to increase clarity from “pre- and post-infusion for 
day of infusion” to “pre- and post-infusion on the day of infusion”. 
o Footnote f – Added “(voluntary)” after (APOE) genotyping to indicate that this is 
optional and patients may opt out of this assessment. 
• Section 5.4.1 Screening and Consent (Day 1-10) 
o Revised the first bullet to add additional clarity surrounding the timing for 
screening and consent. 
o Added “(Optional)” in front of “Buccal swab” to clarify that this analysis is 
voluntary and not required for participation. 
• Section 5.4.2 Day of Infusion (Day 3-10), assessments 
o Added “(Optional)” to clarify that collection of research blood samples for 
biomarkers/immune-panel analysis is in-fact, voluntary. 
o Revised language surrounding NIHSS to clarify that the assessment should be 
performed prior to the start of the infusion and administration of pre-meds. 
o  Added language to clarify that the neurological and physical exams should be 
performed before pre-meds and infusion and post infusion. 
o Added language to ensure that the safety questionnaire was also performed during 
the infusion visit 
o Added guidance to clarify that if on the day of infusion the patients NIHSS is <6, 
they will remain eligible for infusion. 
o Added guidance to clarify that subjects with >4 point increase of NIHSS from 
time of consent (worsening of score) will not be eligible for infusion. 
• Section 5.4.3 Follow-up phone call or visit 24-hour post infusion 
o Added “(Optional)” to clarify that collection of research blood samples for 
biomarkers/immune-panel analysis is in-fact, voluntary. 
 
Summary of Amendment 05, September 2017 
The protocol was amended as follows: 
• Protocol summary (summary): 
o Removal of race as criteria for selection of UCB unit. 
o Removal of “baseline” from “Patients will have baseline magnetic resonance 
imaging (MRI) at baseline and will be assessed at 1, 3, 6, and 12 months for 
functional outcomes.” 
• Protocol summary (population) – Revised population summary (page 4) – added “and 
ALC ≥ 1200 for African American patients and ≥1500 for all other racial-ethnic groups.” 
• Protocol summary (exploratory endpoints) - Included “Research Blood Samples” to 
further define 90-day exploratory endpoints. 
• Protocol summary (number of centers enrolling) – Expanded from “4 centers” to “4 up to 
6 centers”. 
• Section 1.3.2 – Added a brief description of the aims for the spleen sub-study.  
• Section 2.0 – Removed race from selection criteria for cord blood units. 
• Section 3.1 – Removed race as selection criteria for CBUs. 
• Section 3.2.2: 

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o  Modified inclusion criteria to reduce ALC for African Americans to ≥1200 from 
≥1500.  
o  Modified inclusion criteria by removing race from selection criteria for CBUs. 
• Section 3.2.3.1 – Amended exclusionary medical conditions so that pregnancy can be 
documented by blood test or lactating  
• Section 3.2.3.3 – Removed section. The exclusion for pregnant or lactating women is 
documented in section 3.2.3.1 (#18). The exclusion of those unable or unwilling to be 
evaluated for follow-up visits is covered in section 3.2.2 (#9).  
• Section 4.1 – Removed race from selection criteria for cord blood units. 
• Section 4.2 – Removed race from selection criteria for cord blood units. 
• Section 4.5 – Updated text to reflect that the placebo, along with the previously 
mentioned cells, expire after 6 hours at room temperature. 
• Section 4.6: 
o Updated when vital signs should be checked to “before the infusion, every 5 
minutes during the infusion, at the end of the infusion, then as scheduled in MOP-
01 until 4 hours post infusion.”   
o Replaced vital signs “oxygen saturation” to “pulse oximetry”. 
• Table 5: 
o Replaced “safety follow-up” with “safety questionnaire”  
o “Physical” and “Neurological” exams have been merged. 
o “Biomarker panel” is now referred to as “Research Blood Samples”. 
o Updated foot note references. 
o (d)Added comment in footer regarding tube type and volume for HLA typing 
being sent to MD Anderson. 
o (d and e) Included mention of ESR and CRP tests in footnotes. 
o (f) Added “or at 90-day visit” to “Apolipoprotein E (APOE) genotyping will be 
performed on a buccal swab sample collected during screening or at any time 
prior to hospital discharge or at 90 day visit”.   
o (g) revised “biomarker/immune panel” to “research”. Also included information 
about tube types and volumes. 
o (h) Revised to “before administration of premeds”; previously “post-infusion”.  
• Section 5.4.1: 
o Added ESR and CRP tests to screening visit. 
o Revised order of assessments/procedures to be consistent with Table 5. 
o The following laboratory tests were excluded from the restriction of collection 
within 48 hours of screening: the ABO/Rh typing, lipid profile, coagulation panel, 
CBC and differential, and troponin. If these were performed as standard of care 
upon admission, the results can be used for screening, even if they are greater than 
48 hours old. 
o Added “or at 90-day visit” to “Buccal swab collected for APOE genotyping at 
screening, prior to hospital discharge or at 90 day visit.” 
• Section 5.4.2: 
o  Updated when vital signs should be checked to “before the infusion, every 5 
minutes during the infusion, at the end of the infusion, then as scheduled in MOP-
01 until 4 hours post infusion.”   
o Removal of post infusion scan of spleen 

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o Revised order of assessments/procedures to be consistent with Table 5. 
o Removal of “Neurological exam (post infusion)” from assessments. 
o  
• Section 5.4.3: 
o Wording update - “Blood” samples for biomarkers/immune-panel analysis was 
updated to “research blood samples”. 
o Revised order of assessments/procedures to be consistent with Table 5. 
• Section 5.4.4: 
o Replaced “safety follow-up” with “safety questionnaire”. 
• Section 5.4.5: 
o Replaced “safety follow-up” with “safety questionnaire”. 
o Removed “HLA typing” from laboratory tests. 
o Wording update - “Blood” samples for biomarkers/immune-panel analysis was 
updated to “research blood samples”. 
o Removal of “Optional scan of spleen at selected sites”. 
o Added ESR and CRP tests to 90-day post infusion visit. 
o Revised order of assessments/procedures to be consistent with Table 5. 
• Section 5.4.6: 
o Replaced “safety follow-up” with “safety questionnaire”. 
o Revised order of assessments/procedures to be consistent with Table 5. 
• Section 6.1: 
o Increased the estimated number of research participants to be enrolled each month 
from “4” to “4-6”. 
o Increased the number of centers from “4” to “4-6”. 
• Section 6.7 - Increased the number of centers from “4” to “4-6”. 
 
Summary of Amendment 1, May 2017 
The protocol was amended in order to provide consistency between sections and clarification to 
study procedures, as well as to correct typographical errors. The following changes were made: 
• Section 1.5.2: 
o Total number of AE’s reported as of June 2016 was updated to 115 (previously 
88).  
o The number of serious AE’s was changed from 4 to 8, 6 of which occurred in one 
study patient and 2 in a second patient. 
o The SAE incidence rate, defined as the number of patients experiencing an event 
divided by the number receiving treatment, was revised to 20% (previously 10%)  
• Table 3: 
o Corrected the age of patient number 6 to 51 years (previously 41). 
• Added a new table: 
o “Table 4: CoBIS Phase 1 – Outcomes and Adverse Events” 
• Section 4.3 
o Changed to “If able” ABO will be measured after thawing to cross-check pre- 
cryopreservation data prior to infusion. 

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• Section 4.6: 
o Added time requirement for measuring vital signs during the infusion – Now 
reads “Vital signs (heart rate, blood pressure, temperature, respiratory rate, 
oxygen saturation) will be checked before the infusion, every 5 minutes during 
the infusion, at the end of the infusion, every 15 minutes for 1 hour after the 
infusion and then hourly until 4 hours post infusion.” 
• Table 5: 
o Removed “Eligibility”. 
o Separated “Physical Exam” and “Neurological Exams”  
o Added “Vital Signs” 
o Renamed “Clinical lab testing” to “Laboratory testing” 
o Renamed “Research lab” to Buccal swab” 
o Added “Biomarker Panel” 
o Added “Pre-medications”, “Infusion of UCB or placebo”, “IV hydration” and 
“TICS” 
o Removed “Safety questionnaire”. 
o Updated the schedule for “Safety follow-up” and “Concomitant medications” 
o Updated performance criteria for Apolipoprotein E genotyping so that buccal 
swab sample collection may be collected during screening or “at any time prior to 
hospital discharge.” 
o 
h now indicates “Post infusion” 
o Added a new note - l  = NIHSS should be done 24 hours post infusion and daily 
post infusion for 7 days or until discharge 
• Section 5.4.1: 
o Revised “History” to “Medical History” 
o Revised “Physical” to “Physical exam” 
o Revised “Clinical Laboratory Tests” to “Laboratory Tests” 
o Revised criteria for NIHSS performance to “should be performed daily beginning 
the day of consent through the day of infusion (prior to infusion of the UCB cells 
or placebo), within 24 hours of administration of post-infusion fluids, and for up 
to 7 days post-infusion or until discharge.” 
• Section 5.4.2: 
o Added a requirement for the review of pre-infusion labs by study staff which 
reads: “Results of labs related to the inclusion/exclusion criteria should be 
reviewed by the study staff to verify that the subject remains qualified for the 
study prior to infusion. Results for the HLA typing, infectious disease panel, 
direct and indirect Coombs, and HLA antibody screen do not need to be final 
prior to infusion. In addition, clinical labs should be reviewed by the PI or 
designee in order to establish that there are no contraindications to infusion of the 
cord blood.” 
o Added criteria for neurological exam which now reads: “Neurological exam is 
conducted prior to administration of premeds and pre- and post-infusion for day 
of infusion. If subject is to be discharged less than 24 hours post infusion, the 
physical and neurological exam should be performed after administration of post-
infusion fluids but prior to discharge.” 

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o Added criteria for administration of pre-meds which reads: “Administration of 
pre-meds 30-60 minutes prior to the start of the infusion. Premedication consists 
of diphenhydramine 0.5mg/kg/dose IV (maximum 50 mg), hydrocortisone 
1mg/kg /dose IV (maximum 100 mg), and acetaminophen 10-15mg/kg (maximum 
650 mg orally [PO] or per rectum [PR]).  Antihypertensives may be administered 
if clinically indicated or should be made available if needed in a timely manner.” 
o Revised post-infusion cardia-respiratory hemodynamic monitoring and vital signs 
to “15 minutes for 1 hour after the infusion and then hourly until 4 hours post 
infusion.” 
o Revised NIHSS assessment criteria which now reads “within 24 hours after 
administration of post-infusion fluids” 
• Section 5.4.3: 
o Added the following note “NIHSS should be done within 24 hours of 
administration of post-infusion fluids and daily for 7 days post-infusion or until 
discharge.” 
 
• Section 5.4.4: 
o Removed “Safety questionnaire” 
 
• Section 5.4.6: 
o Removed “Safety questionnaire” 
 
 
 
TABLE OF CONTENTS 
INVESTIGATOR SIGNATURE PAGE................................................................................... 17 
1 
BACKGROUND AND HYPOTHESIS............................................................................. 22 
1.1 
OVERVIEW ..................................................................................................................... 22 
1.2 
RATIONALE FOR CELLULAR THERAPY IN ISCHEMIC STROKE ......................................... 22 
1.3 
CORD BLOOD CELLS IN ANIMAL MODELS OF STROKE ................................................... 26 
1.3.1 Possible Mechanisms of UCB Mediated Neuroprotection and Repair ..................... 26 
1.3.2 Optimization of Doses, Route and Timing of UCB .................................................. 27 
1.4 
CLINICAL TRIAL EXPERIENCE WITH CORD BLOOD CELLS IN TREATMENT OF STROKE AND 
OTHER ISCHEMIC BRAIN INJURIES – DUKE UNIVERSITY ............................................................ 32 
1.5 
HUMAN CLINICAL DATA USING AUTOLOGOUS STEM CELLS IN THE TREATMENT OF 
STROKE ...................................................................................................................................... 32 
1.5.1 Clinical Trials of Allogeneic Stem Cells in Patients with Stroke ............................. 34 
1.5.2 Phase 1 Clinical Trial Data in Ischemic Stroke using Allogeneic Cord Blood Cells 35 
1.6 
STUDY RATIONALE AND HYPOTHESES ........................................................................... 40 
1.7 
POTENTIAL RISKS AND BENEFITS................................................................................... 40 

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1.7.1 Known Potential Risks .............................................................................................. 40 
1.7.2 Known Potential Benefits ......................................................................................... 41 
2 
OBJECTIVES AND PURPOSE ........................................................................................ 41 
2.1 
PRIMARY OBJECTIVE ..................................................................................................... 41 
2.2 
SECONDARY OBJECTIVES ............................................................................................... 41 
2.3 
EXPLORATORY OBJECTIVES ........................................................................................... 42 
2.4 
STUDY ENDPOINTS ......................................................................................................... 42 
2.4.1 Primary Endpoint ...................................................................................................... 42 
2.4.2 Secondary Endpoints ................................................................................................ 42 
2.4.3 Exploratory Endpoints .............................................................................................. 43 
2.5 
DESCRIPTION OF OUTCOME MEASURES ......................................................................... 43 
2.5.1 Primary Outcome Measure ....................................................................................... 43 
2.5.1.1 
Modified Rankin Scale (mRS) ........................................................................... 43 
2.5.2 Secondary Outcome Measures .................................................................................. 43 
2.5.2.1 
Safety Assessments ............................................................................................ 43 
2.5.2.2 
National Institutes of Health Stroke Scale (NIHSS) ......................................... 43 
2.5.2.3 
The Barthel Index (BI) ...................................................................................... 44 
2.5.2.4 
European Quality of Life (EQ-5D-3L) .............................................................. 44 
2.5.2.5 
Patient Health Questionnaire Scale (PHQ-8) .................................................. 44 
2.5.2.6 
Stroke Impact Scale–16 (SIS-16) ...................................................................... 44 
2.5.2.7 
Telephone Interview for Cognitive Status (TICS) ............................................. 44 
2.5.2.8 
Stroke Inventory Test Battery (SITB) ................................................................ 45 
2.5.2.9 
Rehabilitation Survey − see Appendix 1 ........................................................... 46 
2.5.2.10 Neuroimaging ................................................................................................... 46 
3 
STUDY DESIGN ................................................................................................................. 47 
3.1 
STUDY DESIGN OVERVIEW AND DURATION ................................................................... 47 
3.2 
RESEARCH PARTICIPANT SELECTION AND WITHDRAWAL .............................................. 48 
3.2.1 Study Population ....................................................................................................... 48 
3.2.2 Inclusion Criteria ...................................................................................................... 48 
3.2.3 Exclusion Criteria ..................................................................................................... 49 
3.2.3.1 
Exclusionary Medical Conditions: ................................................................... 49 
3.2.3.2 
Prohibited Concomitant or Prior Therapies..................................................... 50 
3.3 
EARLY WITHDRAWAL OF RESEARCH PARTICIPANTS ..................................................... 51 
3.3.1 Off-study Criteria ...................................................................................................... 51 
4 
STUDY PRODUCT ............................................................................................................ 51 
4.1 
ALLOGENEIC UMBILICAL CORD BLOOD ........................................................................ 51 
4.2 
SELECTION OF ALLOGENEIC CORD BLOOD UNITS ......................................................... 51 

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4.3 
CORD BLOOD UNIT CHARACTERIZATION PRE-CRYOPRESERVATION AND AFTER THAWING
 
52 
4.4 
PREPARATION OF PLACEBO ............................................................................................ 53 
4.5 
TRANSPORT OF STUDY PRODUCT ................................................................................... 53 
4.6 
ADMINISTRATION OF ALLOGENEIC UMBILICAL CORD BLOOD OR PLACEBO .................. 53 
4.7 
CARE DURING UNEXPECTED EVENTS ............................................................................. 54 
5 
STUDY PLAN ..................................................................................................................... 54 
5.1 
SCHEDULE OF PROCEDURES AND ASSESSMENTS ............................................................ 54 
5.2 
PATIENT INTERVIEW ...................................................................................................... 58 
5.3 
ASSESSMENT OF PATIENT CAPACITY TO CONSENT: ....................................................... 58 
5.4 
SCREENING, CONSENT, STUDY VISITS AND FOLLOW-UP PHONE CALLS ......................... 58 
5.4.1 Screening and Consent (Day 1-10) ........................................................................... 58 
5.4.2 Day of Infusion (Day 3-10) ....................................................................................... 59 
5.4.3 Follow-up phone call or visit 24 hour post infusion ................................................. 60 
5.4.4 Follow-Up Phone Call or Visit (Day 30 ± 7 days) ................................................... 61 
5.4.5 Visit 1 – 90 Days Post Infusion (± 14 days) ............................................................. 61 
5.4.6 Follow-up phone call (6 months ±14 days) .............................................................. 61 
5.4.7 Follow-up phone call (12 months ±14 days) ............................................................ 61 
6 
STATISTICAL CONSIDERATIONS .............................................................................. 62 
6.1 
ACCRUAL ....................................................................................................................... 62 
6.2 
STUDY DURATION .......................................................................................................... 62 
6.3 
DEMOGRAPHICS AND BASELINE CHARACTERISTICS ...................................................... 62 
6.4 
DESCRIPTION OF THE PRIMARY EFFICACY OUTCOME MEASURE .................................... 62 
6.5 
SAMPLE SIZE AND POWER CALCULATIONS .................................................................... 63 
6.6 
CORRECTION FOR MULTIPLE TESTING ........................................................................... 64 
6.7 
RANDOMIZATION PLAN.................................................................................................. 64 
6.8 
ANALYSIS PLAN ............................................................................................................. 65 
6.8.1 Analysis Populations (see SAP for further details): ................................................. 65 
6.9 
INTERIM ANALYSIS ........................................................................................................ 65 
7 
SAFETY AND ADVERSE EVENT REPORTING ......................................................... 65 
7.1 
ADVERSE EVENTS .......................................................................................................... 65 
7.1.1 Serious Adverse Events ............................................................................................ 66 
7.1.2 Grade/Severity .......................................................................................................... 66 
7.1.3 Suspected Adverse Reaction ..................................................................................... 66 
7.1.4 Causality ................................................................................................................... 66 
7.2 
ADVERSE EVENT REPORTING......................................................................................... 66 
7.3 
SERIOUS ADVERSE EVENT REPORTING .......................................................................... 67 
7.4 
ELICITING ADVERSE EVENT INFORMATION ................................................................... 67 

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7.5 
STOPPING GUIDELINES ................................................................................................... 67 
7.6 
PATIENT REPLACEMENT ................................................................................................ 68 
8 
DATA SAFETY MONITORING BOARD (DSMB) ....................................................... 68 
9 
DATA HANDLING AND QUALITY ASSURANCE ..................................................... 68 
9.1 
CASE REPORT FORMS .................................................................................................... 68 
9.2 
INSPECTION OF RECORDS ............................................................................................... 68 
9.3 
STUDY RECORD RETENTION .......................................................................................... 69 
10 ADMINISTRATIVE ASPECTS........................................................................................ 69 
10.1 
CONFIDENTIALITY ......................................................................................................... 69 
10.2 
INSTITUTIONAL REVIEW BOARD APPROVAL .................................................................. 69 
10.3 
MODIFICATION OF THE PROTOCOL ................................................................................. 70 
10.4 
INFORMED CONSENT ...................................................................................................... 70 
10.5 
PROTOCOL VIOLATIONS AND DEVIATIONS..................................................................... 70 
10.6 
STUDY REPORTING REQUIREMENTS ............................................................................... 71 
11 FINANCIAL OBLIGATIONS .......................................................................................... 71 
12 STUDY CONDUCT ............................................................................................................ 72 
13 PUBLICATIONS ................................................................................................................ 72 
14 REFERENCES .................................................................................................................... 73 
15 APPENDIX .......................................................................................................................... 79 
 
 
List of Tables and Figures 
Table 1 Clinical Studies of Allogeneic Stem Cells in Treatment of Acute and Chronic Ischemic 
Stroke – ClinicalTrials.gov, accessed June 2016. ......................................................................... 24 
Table 2 Completed Stroke Studies Using Autologous Stem Cells ............................................ 33 
Table 3 CoBIS Phase 1 – Patient Demographic and Cell Infusion Characteristics ................... 37 
Table 4 CoBIS Phase 1 – Outcomes and Adverse Events ......................................................... 39 
Table 5 Schedule of Study Procedures and Assessments .......................................................... 55 
Table 6   Sample Size Parameters ……………………………………………………………….63 
Figure 1 
IV administration of Human UCB in an MCAO Mouse Model of Ischemic Stroke 29 
Figure 2 
Mouse Model of Stroke infused with HUCB on either Day 2 or Day 5 Post MCAO
 
30 
Figure 3 
Study Flow Chart .................................................................................................... 488 
 

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INVESTIGATOR SIGNATURE PAGE 
Phase 2 Study of Allogeneic Umbilical Cord Blood Infusion for Adults with Ischemic 
Stroke – CoBIS 2 
Protocol Version 4.0, 19 February 2018 
I agree to conduct and supervise this clinical study in accordance with the design and 
specific provisions of this protocol; modifications to the study or protocol are acceptable 
only with a mutually agreed upon protocol amendment except when necessary to protect 
the safety of patients. I agree to await IRB approval for the protocol and informed 
consent before initiating the study, and to obtain informed consent from patients prior to 
their enrollment in the study. I agree to report to responsible regulatory agencies and IRB 
(when necessary) adverse events that occur in the course of this investigation. I agree to 
maintain accurate and adequate records in the case report forms as required by this 
protocol and maintain those records for the period of time required. I will make the study 
documentation available for safety oversight committee review and/or for other 
inspections as required. I agree to maintain study documentation for the period of time 
required.   
I agree to comply with all other requirements regarding the obligations of clinical 
investigators according to FDA regulations and guidance, and to conduct this study 
according to the principles of the International Council on Harmonisation E6 Guideline 
on GCP and the principles of the World Medical Association Declaration of Helsinki. I 
will conduct all aspects of this study in accordance with all national, state, and local laws 
or regulations. 
I agree to ensure that all people assisting in the conduct of this study are informed in 
meeting the above commitments. 
 
________________________________ 
(Investigator’s printed name) 
________________________________ 
(Investigator’s signed name) 
 
 

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ABBREVIATIONS 
Abbreviations:  
 
ACTIsSIMA 
Study of Modified Stem Cells (SB623) in Patients with Chronic Motor Deficit 
From Ischemic Stroke 
ADL/ IADL 
Activities of daily living/instrumental activities of daily living   
AE 
Adverse Event 
ALC 
Absolute Lymphocyte Count 
ANC 
Absolute Neutrophil Count 
anti-HBc 
Hepatitis B Core Antibody 
APC 
Antiphospholipid Syndrome 
ApoE 
Apolipoprotein E 
BDNF 
Brain Derived Neurotropic Factor 
BI 
Barthel Index 
BMSC 
Bone Marrow Stromal Cell 
CBU 
Cord Blood Unit 
CCBB 
Carolinas Cord Blood Bank 
CDE 
Common Data Elements 
CFR 
Code of Federal Regulations 
CFU 
Colony Forming Unit 
CHI 
Catholic Health Initiative 
CIBMTR 
Center for International Blood and Marrow Transplant Research 
CLIA 
Clinical Laboratory Improvement Amendments 
COWAT 
Controlled Oral Word Association Test 
CMV 
Cytomegalovirus 
CNS 
Central Nervous System 
CoBIS 2 
Phase 2 Study of Allogeneic Umbilical Cord Blood Infusion for Adults with 
Ischemic Stroke 
CP 
Cerebral Palsy 
CRF 
CRP 
Case Report Form 
C-Reactive Protein 
CT 
Computed Tomography 

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CTCAE 
Common Terminology Criteria for Adverse Events 
CTX 
CTX0E03 human neural stem cell product (ReNeuron; Surrey, England) 
DMSO 
Dimethyl Sulfoxide 
DSMB 
Data Safety Monitoring Board 
DTI 
Diffusion Tensor Imaging 
DWI 
Diffusion Weighted Imaging 
EBST 
ESR                  
Elevated Body-Swing Test 
Erythrocyte Sedimentation Rate 
EQ-5D 
European Quality of Life 
FDA 
Food and Drug Administration 
FDR 
False Discovery Rate 
FGF 
Fibroblast Growth Factor 
F-MA 
Fugl-Meyer Assessment 
FSPGR 
Fast Spoiled Gradient Echo 
GCP 
Good Clinical Practice 
GvHD 
Graft versus Host Disease 
H0 
Null hypothesis 
HA 
Alternative hypothesis 
HBV 
Hepatitis B Virus 
HCV 
Hepatitis C Virus 
HIE 
Hypoxic Ischemic Encephalopathy 
HIV 
Human Immunodeficiency Virus 
HLA 
Human Leukocyte Antigen 
HTLV I/II 
Human T cell Lymphotropic Virus-1 and -2 
HUCB 
Human Umbilical Cord Blood 
HVLT-R 
Hopkins Verbal Learning Test-Revised 
ICH 
Intracerebral Hemorrhage 
IL-1-ß 
Interleukin-1-beta 
IL-2 
Interleukin-2 
IRB 
Internal Review Board 
ISBT 
International Society of Blood Transfusion 
IV 
Intravenous 

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LAR 
Legally Authorized Representative 
LUQ 
Left Upper Quadrant 
MCA 
Middle Cerebral Artery 
MCAO 
Middle Cerebral Artery Occlusion 
MMP9 
Matrix Metallopeptidase 9 
MMSE 
Mini-mental State Examination 
MoCA 
Montreal Cognitive Assessment 
MRI 
Magnetic Resonance Imaging 
mRS 
Modified Rankin Scale 
MSC 
Mesenchymal Stem Cells 
NAT 
Nucleic Acid Testing 
NCT 
National Clinical Trial [identifier number] 
NIH 
National Institute of Health 
NIHSS 
National Institutes of Health Stroke Scale 
NINDS 
National Institute of Neurological Disorders and Stroke 
NM 
Neuromuscular 
NSS 
NeuroSeverity Score 
OR 
Odds Ratio 
PHQ-8 
Patient Health Questionnaire 8 
PI 
Principal Investigator 
PISCES 
Pilot Investigation of Stem Cells in Stroke 
PR 
Per Rectum 
PRA 
Panel Reactive Antibody 
RR 
Rotarod 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SB623 
Modified Allogeneic Mesenchymal Stem Cells Derived from Bone Marrow of 
Healthy Human Adult Donors (SanBio, Inc; Mountain View, CA) 
SDMT 
Symbol Digit Modalities Test 
SIS-16 
Stroke Impact Scale-16 
SITB 
Stroke Inventory Test Battery 
SNR 
Signal to Noise Ratio 
SOP 
Standard Operating Procedure 

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SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TC-199 
Tissue Culture Medium 199 (pink) 
TICS 
Telephone Interview for Cognitive Status  
TNCC 
Total Nucleated Cell Count 
TNFα 
Tumor Necrosis Factor-alpha 
tPA 
Tissue Plasminogen Activator 
UCB 
Umbilical Cord Blood 
UCMSC 
Umbilical cord mesenchymal stem cell 
ULN 
Upper Limits of Normal 
VEGF 
Vascular Endothelial Growth Factor 
 
 
 
 
 
 

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1 
BACKGROUND AND HYPOTHESIS  
1.1 
Overview 
Stroke is a major cause of death and long-term disability, affecting one in every six people 
worldwide. Approximately 795,000 Americans suffer a stroke each year, 140,000 of which result 
in fatality, making stroke the third leading cause of death in the US.2-4 Although stroke can occur 
at any age, the majority (~75%) occur among individuals over the age of 65, and risk of stroke 
more than doubles each decade after the age of 55. The costs associated with stroke in the US, 
including health care services, medication, follow-up and missed work days, total approximately 
$36.5 billion each year.  
About 88% of all strokes are ischemic strokes, which occur when blood flow to the brain is 
blocked by a clot or mechanical event. Following vascular occlusion, a complex chain of events 
occur at a molecular level leading to irreversible tissue injury, including failure of energy 
synthesis and loss of transmembrane ionic gradients dependent on active transport. In the region 
with severely reduced blood flow, processes result in rapid cell necrosis affecting all the cellular 
elements. Rapid restoration of perfusion or blood flow to the surrounding area is the most robust 
predictor of good clinical prognosis following ischemic stroke. Immediately after the stroke, 
edema, loss of sensory input and inflammation occur around the infarct.5 Some early recovery is 
realized with resolution of edema and inflammation but immunomodulation, angiogenesis, 
endogenous neurogenesis, and altered gene expression may be required for long-term recovery.  
To date, no approved pharmacological treatment to promote revascularization in ischemic stroke 
exists outside of intravenous (IV) tissue plasminogen activator (tPA). The most effective use of 
tPA is limited to treatment within 3.0 hours from documented symptom onset, with diminishing 
effectiveness after 4.5 hours.6 Given the time limitations and increased risk of bleeding including 
symptomatic intracerebral hemorrhage (ICH), tPA is used in only about 20% of patients with 
ischemic stroke, and cannot be used in hemorrhagic stroke.6,7 Recent data also suggest the utility 
of mechanical reperfusion via endovascular intervention; however, therapy is limited to patients 
with proximal occlusion, requires specialized facilities, and has greatest benefit when performed 
within 6 hours following stroke onset.8-12 Thus, there remains a compelling unmet need for 
therapies to improve outcome after stroke. 
1.2 
Rationale for Cellular Therapy in Ischemic Stroke 
There is recent evidence that cellular therapy using unrelated donor, banked umbilical cord blood 
(UCB) has potential to favorably alter the natural history of stroke in affected patients. If 
administered within the first few weeks following stroke, UCB cells are thought to modulate 
ischemic damage in part through paracrine signaling to decrease inflammation and promote 
neurogenesis, thereby improving functional outcomes in patients. When banked in an accredited 
public cell bank, UCB is a readily available, prequalified, cryopreserved product that can be 

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selected for the stroke patient and shipped overnight. Thus, allogeneic UCB cells have the 
potential to expand access to therapy to many more patients with stroke.  
The CoBIS Phase 1 clinical study, initiated in June, 2015, demonstrated a favorable safety 
profile based on the treatment of 10 male patients, ages 45 to 79, with an IV infusion of 
0.80-2.00 x 107 TNCC/kg UCB cells from Day 3 to Day 9 post ischemic stroke (Section 1.5.2). 
The results from this Phase 1 safety study indicate that a placebo controlled study is warranted. 
We hypothesize that cell therapy using stem cells from UCB will provide benefit by reducing the 
area of permanent injury, promoting plasticity, and improving functional outcomes for these 
patients. Cell therapy may favorably alter the natural history of these processes through paracrine 
signaling that reduces inflammation, promotes angiogenesis, neurogenesis and recruitment of 
endogenous cell repair. 
Human UCB has been widely used as a donor graft for allogeneic, unrelated donor 
hematopoietic stem cell transplantation for more than two decades,13  predominantly to treat 
patients with refractory malignancies or potentially lethal genetic diseases. For those indications, 
the intent is for donor cells to effect permanent engraftment, providing life-long support of the 
hematopoietic and immune systems. When long-term engraftment is the goal, the patient must 
undergo immunosuppression and myeloablation prior to the infusion of donor cells.  
In contrast, for the indication of ischemic stroke, the desired paracrine effects and recruitment of 
cells to the area of injury can be achieved with short-term presence of donor cells in the 
recipient, thus eliminating the need for immunosuppression. The proposed therapy of allogeneic 
UCB cells given to immunocompetent patients with no prior immunosuppression is based on the 
assumption that UCB cells will ultimately be rejected by an immunocompetent host, without 
sustained engraftment.  
In animal models of brain injury from ischemic stroke, extensive data support the safety profile 
of the infusion of allogeneic cord blood cells, as well as improvements in functional recovery 
(Section 1.3). Recent, but limited, pilot trials in human stroke patients support the safety of 
infusion of expanded or non-expanded allogeneic cells from cord blood, umbilical cord, adipose 
tissue and bone marrow without immunosuppression and myeloablation. A recent search on 
ClinicalTrials.gov identified 11 current clinical trials of allogeneic stem cells for the treatment of 
patients with acute and chronic ischemic stroke (see Table 1). While a number of these trials 
employ allogeneic cells isolated from bone marrow or adipose tissue, four of them, including the 
previously cited CoBIS Phase 1 stroke trial, use UCB cells. Three other trials are based on 
proprietary modified cell lines (SB623 cells [SanBio, Inc]; CTX cells, [ReNeuron Ltd.]) or a 
proprietary stem cell product (MultiStem; NCT01436487) derived from mononuclear bone 
marrow cells.  

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Table 1: Clinical Studies of Allogeneic Stem Cells in Treatment of Acute and Chronic Ischemic Stroke – 
ClinicalTrials.gov, accessed June 2016. 
Phase 
Cell Type 
Delivery 
Route 
Intervention 
Inclusion Criteria 
Number of 
Patients 
Planned 
Country/ PI 
NCT 
identifier 
Status 
II 
MSC's from 
adipose 
tissue 
IV 
1 x 10⁶ 
cells/kg, 
within first 2 
wk after onset 
Acute cerebral infarction (<12h):  
60-80 yr old; NIHSS 8-20 
20 
Spain/  
Diez Tejedor 
NCT01678534 
Recruiting 
 
I/II 
Adult 
BMSC's 
IV 
0.5-1.5 x 10⁶ 
cells/kg 
Chronic ischemic stroke (>6m); 
>18yr old; NIHSS 6-20 
38 
US/ Stemedica Cell 
Tech., 
Lev Verkh  
NCT01297413 
Active, Not 
Recruiting 
I/IIA 
Modified 
stromal cells 
(SB623) 
IC 
2.5, 5.0, or  
10 x 10⁶ cells 
Ischemic stroke in subcortical 
region of MCA: > 18 – 75 yr 
old; (6-60m) or  
Lenticulostriate artery w/wo 
cortical involvement 
Phase 1 = 
18; 
Phase 2= 
156 
USA/San Bio Inc.,  
Gary Steinberg, 14  
ACTIsSIMA    
Phase 1 = 
NCT01287936   
Phase 2 = 
NCT02448641 
Active, Not 
Recruiting 
I/II 
Immortalized 
fetal Neural 
stem cells, 
CTX cells 
IC 
2 x 10⁶ cells 
Ischemic stroke (2-3m);  
40-89 yr old;  
NIHSS >2 upper extremity 
Phase1 = 12   
Phase 2 = 41 
UK/ 
ReNeuron,  
Kevin Muir 
PISCES        
Phase 1 = 
NCT01151124 
Phase 2 = 
NCT03117635 
Phase 1 = 
Active, Not 
Recruiting    
Phase 2 = 
Recruiting 
I/II 
BM derived 
MSC's 
IV 
MTD max. 
total dose 
Acute ischemic stroke 
(3-10 days);  
18-83 yr old; NIHSS 7-25; 
Planned, 48;  
only got 10 
Houston 
Sean Savitz 
SAMCIS 
NCT01922908 
Not Yet 
Recruiting 
II 
Adult Stem 
Cells Product 
'Multi Stem' 
IV 
Low 4-
12 x 10⁸ 
MAPCs high 
dose 
Moderate to Moderate severe 
cortical cerebral ischemic stroke 
(1-2d); 18-83 yr old 
n = 140 
USA/Athersys, Inc; 
David Hess, Robert 
Mays 
NCT01436487 
Completed 
I/II 
Cord Stem 
Cells; Cord 
IV 
2 x 10⁸ cells; 
0-7 days after 
stroke 
19-80 yr old; 0-7 days after 
stroke; NIHSS 5-20 involving 
anterior circulatory region 
18 
Korea/ 
CHA BioTech Co 
NCT02378974 
Recruiting 
I 
Allo UCBs; 
Cord 
IV 
0.5-5 x 10⁷ 
cells; 3-
10 days 
Ischemic Stroke; 18-80 yr old; 3-
10 days after stroke; NIHSS 8-
18 
n =10 
US/  
Duke University 
Joanne Kurtzberg 
CoBIS 
NCT02397018 
Active, Not 
Recruiting 

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Phase 
Cell Type 
Delivery 
Route 
Intervention 
Inclusion Criteria 
Number of 
Patients 
Planned 
Country/ PI 
NCT 
identifier 
Status 
IIa 
Allo 
UCMSC 
IV 
2 x 10⁷ 
UCMSCs 
weekly for 4 
weeks 
Stroke within 3 mo; 70 yr old 
2 
China/Sheng et al; 
 PI: Duan Lian 
NCT02580019 
Not Yet 
Recruiting 
I 
Allo UCB 
mononuclear 
cells 
IC 
10-40 x 10⁶ 
cells 
35-65 yr old; Ischemic Stroke(6-
60 mo) MCA; NIHSS 5-15 
12 
 
 
China/China Spinal 
Cord Injury Network 
NCT01673932 
Recruiting 
I 
Allo 
UCMSC 
IA 
2 x 10⁷ cells 
Stroke within 3 mo; MCA; 
Patients < 60 years old; included 
3 ischemic and 1 hemorrhagic 
4 
Jinling Hospital27 
Nanjing, China 
N/A/China 
Completed 
PI, Principal Investigator; NCT, National Clinical Trial [identifier number]; MSC, mesenchymal stem cells; IV, intravenous; IC, intracranial; IA intra-arterial; NIHSS, 
National Institutes of Health Stroke Scale; BMSC, bone marrow stromal cell; US, United States; Allo, allogeneic; SB623, modified allogeneic mesenchymal stem cells 
derived from bone marrow of healthy human adult donors (SanBio, Inc; Mountain View, CA); NM, neuromuscular; MCA, middle cerebral artery; CTX, CTX0E03 
human neural stem cell product (ReNeuron; Surrey, England); UK, United Kingdom; BM, bone marrow; MTD, maximum total dose; MAPC, multipotent adult progenitor 
cells; UCB, umbilical cord blood; UCMSC, umbilical cord mesenchymal stem cell. 
Trial acronyms:  ACTIsSIMA – Study of Modified Stem Cells (SB623) in Patients with Chronic Motor Deficit From Ischemic Stroke;  
PISCES – Pilot Investigation of Stem Cells in Stroke;  
SAMCIS — Mesenchymal Stromal Cells for Ischemic Stroke; MAPC; 
CoBIS  –Study of Allogeneic Umbilical Cord Blood Infusion for Adults with Ischemic Stroke. 

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One major advantage of UCB cells in allogeneic hematopoietic stem cell transplantation is that 
they are immunologically tolerant, rendering them less reactive to human leukocyte antigen 
(HLA)-mismatch than bone marrow or mobilized peripheral blood grafts.15 Consequently, 
candidates for allogeneic cell transplant who do not have a fully HLA-matched adult donor can 
receive partially HLA-mismatched cord blood donor units without risking unmanageable graft 
versus host disease (GVHD). This has increased access to transplantation therapy for patients 
with hematological malignancies, congenital immunodeficiency syndromes, bone marrow failure 
syndromes, hemoglobinopathies, and certain inherited metabolic diseases affecting the brain, 
where improvements in neurologic function have been seen.16,17 Similarly, UCB may represent a 
more tolerable option for medically fragile stroke patients, who might otherwise need to undergo 
additional procedures, e.g., bone marrow harvest or peripheral stem cell collection; for collection 
of autologous cells. Unlike patients with malignant and genetic diseases, UCB infusions in 
patients with stroke are not intended to durably engraft the hematopoietic or immune systems, 
but rather to circulate and temporarily survive in vivo for sufficient time to alter behavior of 
endogenous host cells through paracrine signaling. Permanent engraftment is not a goal and, as 
such, myelo- and/or immunoablation will not be used in the present study. 
1.3 
Cord Blood Cells in Animal Models of Stroke 
Data from animal models of stroke support the safety of UCB cells, as well as their association 
with improvements in functional recovery. The most extensively studied models are of rodents 
with ischemic brain damage resulting from permanent middle cerebral artery occlusion (MCAO) 
in adult rats or transient MCAO accompanied with hypoxia in neonatal rats or mice. Occlusion in 
the animal models is followed by sequential pathogenic processes starting with massive release 
of excitogenic amino acids, microglial and astrocytic activation, immune cell infiltration, a 
protracted inflammatory cytokine storm, and ultimately neuronal death and tissue infarction.19-22 
Given the xenogenic introduction of human cells into a rodent model, rejection by circulating 
antibodies and complement would be expected; however, there have been no observations of 
animal weight loss due to cellular therapy or any indication of GVHD symptoms. In most animal 
studies of induced brain ischemia and stroke, human UCB (HUCB) treatment has instead been 
associated with indicators of anti-inflammatory activity and altered balance of splenic 
lymphocyte populations favoring anti-inflammatory outcomes, suggesting that host response to 
HUCB therapy may be sustained after the cells have been eliminated.20  This is consistent with 
animal studies showing that UCB cells can repair hypoxic/ischemic damage even though the 
cells do not persist for long periods of time in the brain.23 
1.3.1 
Possible Mechanisms of UCB Mediated Neuroprotection and Repair 
The ability of UCB to ameliorate various types of central nervous system (CNS) damage has 
been shown in tissue culture and animal studies. While the exact pathways by which UCB cells 
lead to neural sparing and recovery have yet to be completely elucidated, several mechanisms 
have been hypothesized on the basis of animal studies.24  Transplanted cells may migrate to the 

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affected ischemic area and deliver trophic factors that provide anti-inflammatory and 
neuroprotective effects and enhance the potential for survival of host cells.25,26 
• 
UCB cells may result in increased plasticity of the injured brain by enhancing 
synaptogenesis, neovascularization, and endogenous repair mechanisms and by 
inducing migration and proliferation of endogenous neural stem cells.27  Evidence of 
the angiogenic potential of human bone marrow cells is supported by mouse studies 
demonstrating revascularization of surgically-induced ischemic limbs after IV 
transplantation.28  Stem cells may also infiltrate, proliferate, and differentiate into 
“replacement” neuronal and glial cells and play a role in remyelination.  
• 
Human hematopoietic progenitor cells derived from multiple sources and administered 
via the IV, intraperitoneal, and intracerebral routes have demonstrated the ability to 
enhance functional recovery in multiple animal models of stroke.29 
Significantly, in certain contexts, UCB cells dampen, rather than augment, inflammatory 
responses through an increase of regulatory T cell populations and the generation of 
monocyte/dendritic cell anti-inflammatory cytokines. In this regard, it is plausible to consider a 
population of UCB cells as an anti-inflammatory agent. In animal models of stroke, 
pro-inflammatory cytokines increase after ischemic brain damage in the affected areas and can 
be readily measured. Conversely, at both the protein and ribonucleic acid (RNA) level, IL-2, 
TNFα and IL-1-ß were shown to be decreased after HUCB treatment in a rat model of stroke.23  
There is evidence that the effects of cord blood cells in the regeneration and repair processes 
following ischemic stroke are through signaling that increases neurogenesis and angiogenesis in 
areas proximal to the infarct.30 
Additional preclinical work has shown that within the HUCB milieu, monocytes (CD14+) are 
the critical cellular component responsible for neuroprotective and anti-inflammatory effects 
following ischemic brain injury. In a model of stroke induced by MCAO, rats post occlusion 
were injected with HUCB preparations depleted either of monocytes (CD14+), stem cells 
(CD133+), T cells (CD2+) or B cells (CD19+). The group receiving the CD14+ depleted cells 
had the largest and most consistent decrements in behavioral recovery and increased infarct size, 
with activity levels and infarct size similar to untreated MCAO rats.18 
1.3.2 
Optimization of Doses, Route and Timing of UCB 
The dose dependence of HUCB effect on neurologic recovery has been demonstrated by 
Vendrame et al.31,32  Rats were treated 24 hours after MCAO with doses of HUCB ranging from 
1 x 105 to 5 x 107 cells. Behavioral and histological evaluations of the infarct volume clearly 
showed a dose-dependent effect: only the groups dosed with ≥ 1 x 106 cells were associated with 
positive outcomes. 

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In a rat model of collagenase-induced intracerebral hemorrhage (ICH), neurologic deficits were 
ameliorated by a single IV injection of cryopreserved human UCB cells (HUCB):  animals 
receiving 2.4–3.2 x 106 mononucleated HUCB cells IV demonstrated significant improvements 
in the neurologic severity test, the stepping test and elevated body-swing test (EBST) compared 
with saline-injected controls.34   
In a murine stroke model, male mice injected at 5 days after transient (25 min) MCAO with 
1 x 106 HUCB cells IV had significant reduction in neurological deficit (improved 
NeuroSeverity Score [NSS]) (p=0.0193), improved 10-day survival (83% vs. 50%, respectively), 
and a reduction in infarct volume, relative to vehicle control (Figure 1). No difference in 
Rotarod (RR) performance was observed between the two cohorts (preliminary results from the 
authors of this protocol (unpublished)). The same authors conducted a second study to determine 
if the time of HUCB treatment after ischemic brain injury affected outcomes:  mice subjected to 
transient MCAO (15 min) were randomized to injection of HUCB at either 2 or 5 days post 
MCAO, or injection of vehicle at 2 days post MCAO. At 10 days post MCAO-induced stroke, 
animals infused with HUCB on either Day 2 or Day 5 exhibited a significant reduction (~2-fold) 
in neurological deficit (improved NSS) (p=0.0329 and 0.0352, respectively) as well as functional 
improvement by RR performance (p=0.0361 and 0.0006, respectively), relative to controls 
(Figure 2). However, no significant difference in infarct size was observed among the three 
cohorts.

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Figure 1: IV administration of Human UCB in an MCAO Mouse Model of Ischemic 
Stroke 
 
A.  
 
B.  
 
 
Figure 1. Thirty 10-12 week old male C57BL6 mice were subjected to MCAO for 25 min. and randomized into two groups: an experimental 
group (UCB) received 1 x 106 HUCB cells (CBC) and vehicle group (DA) received dextran/5% albumin 5 days after MCAO. Outcome was 
assessed 10 days post MCAO. A. Animals receiving HUCB showed a reduction in neurological deficit (improved NSS) relative to vehicle 
controls (P=0.0193). B. Animals treated with HUCB (CBC) had a reduction in infarct size relative to controls (DA).  
P = 0.0193 

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30 | P a g e  
Figure 2: Mouse Model of Stroke infused with HUCB on either Day 2 or Day 5 Post 
MCAO 
 
A.  
 
 
 
 
 
 
 
 
B . 
C 2
C 5
D A
0
1 0
2 0
3 0
4 0
C o rd b lo o d  M C A O
D a y
T o ta l N e u ro s e v e rity  S c o re
C2 vs DA: p = 0.0329  
C5 vs DA: p= 0.0352 
C 2
C 5
D A
0
1 0 0
2 0 0
3 0 0
4 0 0
C o rd b lo o d  M C A O
D a y
R o ta ro d  (s )
C2 vs DA: p = 0.0361 
C5 vs DA: p= 0.0006 
Figure 2. Thirty 10-12 week old male C57BL6 mice were subjected to MCAO for 15 min. and 
randomized into 3 groups:: cohorts 1 and 2 were administered 1 x 106 HUCB at Day 2 (C2) or Day 5 
(C5) post MCAO; control group  received vehicle alone (DA). A. Animals infused with HUCB on days 
2 and 5 exhibited a significant reduction in neurological deficit (improved NSS; p=0.0329 and 0.0352) 
10 days post MCAO. B. Both groups exhibited functional improvement on RR performance relative to 
vehicle controls (p=0.0361 and 0.0006) 10 days post MCAO.  

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Among rats injected with 3 x 106 HUCB IV at either 1 or 7 days after MCAO-induced ischemic 
brain injury, HUCBs were found to have survived and migrated to the damaged brain areas, 
primarily to the ischemic boundary zone. Significant improvements were observed in the group 
administered HUCB 1 day after MCAO but not at 7 days post MCAO, suggesting that early 
administration of HUCB was more efficacious than delayed treatment.23  
Various delivery routes for stem cells have been used in the treatment of neurological disorders 
in both preclinical and clinical studies, including stereotactic transplantation into the brain, intra-
arterial, intrathecal, IV and intranasal delivery, and evidence has been mixed as to whether route 
of cell transplantation impacts the extent of behavioral recovery.35-39 In a rat MCAO model, 
Willing et al compared the effect of HUCBs injected intravenously into the femoral vein or 
directly into the striatum. Although both groups demonstrated improvements in several measures 
of hyperactivity and passive avoidance tests, only the group treated by femoral vein injection had 
significant improvement in the stepping test, an indicator of recovery from asymmetric motor 
deficits.25 Similar conclusions have been made regarding stem cell delivery to treat stroke in 
humans:  among the current stem cell stroke trials listed on ClinicalTrials.gov, the favored 
method of stem cell delivery is intravenous (Table 1). 
In this regard, recent studies suggest that intravenously injected UCB cells interact with the 
immune system in the spleen of experimental animals and elicit the formation of cells or 
cytokines that subsequently have therapeutic effects in the brain.40 Intravenously injected 
mesenchymal cells have similar therapeutic allocrine effects on the brains of animals with stroke 
or traumatic brain injury. Acosta et al recently showed in a rat model of chronic stroke that 
human bone marrow stromal cells (hBMSC) delivered intravenously preferentially migrated to 
the spleen over the brain.41 Furthermore, cells survived better in the spleen relative to the brain, 
which in turn correlated with improvement of neurostructural deficits and inflammation. Coupled 
with down-regulation of TNFα density in the spleen, cell transplantation was associated with 
reduced infarct size and attenuated stroke-induced inflammation in the brain, supporting the 
hypothesis that stem cells provide a therapeutic benefit by acting in the spleen to dampen 
inflammation and subsequent cell death associated with chronic stroke. A (optional) spleen sub-
study will be conducted to verify the natural history of splenic response in stroke patients, and 
investigate the effect of UCB cells in altering the splenic response and correlating this with 
peripheral cytokine and WBC counts.  
In this Phase 2 trial, UCB will be administered intravenously to patients within 3–10 days 
following ischemic stroke. Following IV injection, UCB may elicit local and/or allocrine 
responses to ongoing inflammatory or tissue damage signals that can down regulate brain 
pathology. The activities of UCB that have been documented in laboratory studies are consistent 
with data demonstrating their ability to dampen an ongoing autoimmune and/or inflammatory 
response in the brain and promoting CNS repair.42 Furthermore, our Phase 1 study indicated that 
delivery of UCB intravenously was safe and well tolerated in 10 adults with acute ischemic 
stroke. 

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In summary, literature suggests xenogenic infusion of human UCB cells in animals following 
ischemic injury offers changes in animal behavior representative of recovery. The proportional 
doses of cells used in animal studies have exceeded the proposed human dose in this current 
study with no documentation of animal safety issues. Optimal timing of dose and route of 
administration remain poorly defined. 
1.4 
Clinical Trial Experience with Cord Blood Cells in Treatment of Stroke and 
Other Ischemic Brain Injuries – Duke University 
The rationale for cord blood therapy is based on the hypothesis that UCB cells act through 
paracrine and allocrine mechanisms to modulate and down regulate inflammation and/or immune 
pathology, possibly protecting neurons from further damage and promoting neurorepair. In 
ongoing clinical trials at Duke University, autologous UCB cells have been administered to 
patients with cerebral palsy (CP) and patients with hypoxic ischemic encephalopathy (HIE), both 
diseases thought to arise from an acute hypoxic/ischemic event leading to a pathological cascade 
that closely parallels events in the animal models that have been successfully treated with 
UCB.39,43 In addition, 15 children have been infused with haploidentical or matched sibling cord 
blood on a Phase 1 study over the past year and no safety concerns were identified. 
1.5 
Human Clinical Data Using Autologous Stem Cells in the Treatment of 
Stroke 
There are no Food and Drug Administration (FDA)-approved biomedical treatments using stem 
cells for the core symptoms of stroke. Numerous groups have conducted Phase 1 and 2 clinical 
trials and reported safety of infusion of various autologous cell populations delivered to patients 
with acute (1 day – 9 days), subacute (~10 – 30 days), and chronic (6 – 60 months) stroke. To 
date, approximately 8 such studies have been reported on ClinicalTrials.gov as ‘completed’ 
(Table 2). The majority of these included stem cells isolated from bone marrow, although one 
completed study in chronic stroke patients conducted in China used stem cells isolated from 
peripheral blood (NCT00950521). The results from these clinical trials reported safety of 
infusion of autologous stem cells for the treatment of stroke. Banerjee et al reported significant 
improvement in clinical functional scores and reductions in lesion volume with intra-arterial 
immunoselected CD34+ cells from autologous bone marrow in 5 patients ages 30–80 with acute 
ischemic stroke, with no significant treatment- related adverse effects.44 In a separate study, 
Savitz et al found IV delivery of autologous BMSCs to be safe in the treatment of 10 patients 
ages 18–80 with acute ischemic stroke.45  

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Table 2: Completed Stroke Studies Using Autologous Stem Cells 
Clinical Trials Identifier 
Cell 
Delivery 
Number of 
subjects 
Acute 
Subacute 
Chronic 
Reference 
NCT00761982 Phase 1/2a 
BMSC 
IA 
20 
X 
China Medical University Hospital 
Shinn-Zong Lin  
Moniche et al. Stroke, 2012 46 
NCT00535197 Phase 1 
BMSC 
IA 
5 
X 
Banerjee et al.  
Stem Cells Transl Med 2014 44 
NCT00859014 Phase 1 
BMSC 
IV 
25 
X 
Vahidy et al. Stem Cells Dev. 2013 ; 
Savitz et al. Ann Neurol 2011 47,48 
NCT02425670 Phase 2 
BMSC 
IV 
120 
 
X 
 
Prasad et al. Stroke 2014 49 
NCT01501773 Phase 1 
BMSC 
IV 
9 
X 
Prasad et al. 
Indian J. Med Res 2012 50 
NCT00950521 Phase 2 
Peripheral 
blood CD34+ 
cells 
IC 
30 
X 
Mackie & Losordo  
Tex Heart Institution J. 2011 51 
NCT02065778 Phase 1 
BMSC 
IT 
30 
X 
Borlongan, Leukemia 2011 52 
NCT01028794 Phase 1/2a 
BMSC 
IV 
6 
X 
Taguchi et al.  
Stem Cells and Dev 2015 53 
BMSC, bone marrow stromal cells, IA, intra-arterial injection; IV, intravenous injection. IC, intracranial 
 

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In a Phase 1 study conducted in India, favorable outcomes were described for 9 patients ages 30–
70 with subacute stroke after treatment with IV injection of autologous BMSCs.54 The study was 
expanded to a Phase 2, multicenter, parallel group, randomized trial (n=120), with 58 patients 
receiving BMSCs at a median of 18.5 days after stroke.49 In the larger Phase 2 study, although 
the cells were shown to be safe, response based on the mRS and Barthel Index (BI) at 180 days 
showed no beneficial effect of treatment on stroke outcome. 
1.5.1 
Clinical Trials of Allogeneic Stem Cells in Patients with Stroke 
Treatment with allogeneic HUCB cells without prior immunosuppression has been reported by 
Yang et al in a variety of degenerative conditions including paraplegia, ataxia, multiple sclerosis, 
ALS, brain disease and brain injury.55 Cells from digested cord were evaluated for safety in 
114 humans with no SAEs reported for hematological, immunological and biochemical 
endpoints. By contrast, more approved therapies have been reported for the use of allogeneic 
UCB in patients with inherited metabolic diseases and oncology using prior 
immunosuppression.39  
There are several clinical trials in various stages that are investigating the use of allogeneic cell 
therapy using selected populations of cells for the treatment of ischemic stroke (Table 1). Cell 
products used in these trials are derived from adipose tissue, BMSC’s, umbilical cord, UCB and 
fetal neural stem cells.  
• One completed pilot study in 4 patients with chronic stroke (3 ischemic, 1 hemorrhagic) 
showed treatment with allogeneic mesenchymal stem/stromal cells (MSC’s) isolated 
from umbilical cord was safe and associated with no adverse events (AEs).56 
• Furthermore, in patients with ischemic stroke, but not intracranial hemorrhage, MSCs 
improved the neurological function as assessed by the mRS,57 although the small sample 
size is a major limitation of this study.  
• In contrast, a second completed Phase 2 randomized study using MultiStem, a proprietary 
stem cell product derived from mononuclear bone marrow cells in the setting of acute 
stroke (n=140), found no differences in 90 day outcome between therapy and placebo 
group, although treatment was associated with lower rates of mortality and life 
threatening AEs.58,59 
• An additional group using modified stromal cells (SB623 cells) transplanted into the 
brains of patients suffering from chronic stroke recently reported improvement in clinical 
outcome endpoints at 12 months in a Phase 1 study.14  
• The PISCES stroke trial uses immortalized fetal neural stem cells surgically implanted 
into the brains of patients with chronic stroke and is currently recruiting for a Phase 2 
trial.60  

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• Five studies use stem cells derived from UCB to treat chronic (3) or acute (2) stroke, 
including Duke University’s Phase 1 CoBIS study (Table 1). Compared with BMSCs, 
stem cells from UCB offer improved plasticity, faster growth time, lower immunological 
response against host, and ready availability without the need for invasive procedures in 
compromised patients. Furthermore, umbilical cord stem cells are biologically closer to 
embryonic stem cells than adult BMSCs. 
1.5.2 
Phase 1 Clinical Trial Data in Ischemic Stroke using Allogeneic Cord 
Blood Cells  
Ten adult male patients were treated in a Phase 1 clinical study (CoBIS) at Duke University and 
Houston Methodist Hospital. Table 3 is a summary of patient demographics, dose of UCB cells, 
and window of treatment post the primary stroke event. The participants had a mean age of 
61.5 years (range 45–79); the range of cell doses infused was 0.83–3.34 x 107 TNCC/kg, and 
infusions were administered from 3 to 9 days post stroke. The mRS was used to characterize 
outcome associated with stroke recovery at baseline, 1 month, and 3 months following stroke. 
The NIHSS was used to measure impairments due to stroke at baseline and 3 months after 
stroke; the BI was used to measure basic activities of daily living. Other measures, such as the 
EQ-5D-3L and PHQ-8 were used to measure health status. Table 4 shows change in scores from 
baseline to 3 months. All 10 patients were independent prior to the stroke; 9 patients had an 
historic mRS of 0 (no symptoms at all) and one patient (0101) had an historic mRS of 1 (no 
significant disability despite symptoms; able to carry out all usual activities). Safety was assessed 
at 24 hours, days 3–10, and at 3, 6, and 12 months post infusion. As of June, 2016, a total of 
115 AEs were reported in 10 of 10 patients (Table 4); 8 of these were serious (6 occurring in one 
study patient and 2 in a second patient), were unrelated to study therapy and not reportable. The 
SAE incidence rate, defined as the number of patients experiencing an event divided by the 
number receiving treatment, was 20% (2/10 patients experienced an SAE). All 10 patients 
shifted at least one grade in mRS from baseline (time of infusion) to 3 months after stroke (range 
1-3 points), indicating improved outcome.  
Most stroke patients will show the fastest improvement following a stroke within the first 
month,61 and in one of the few studies examining change in mRS over time, 58% of patients 
disabled by stroke (mRS 3–5) improved at least one grade in their mRS after 3 months.62 The 
CoBIS Phase 1 study results are in agreement with this and show that 50% of the patients 
exhibited a 1 grade increase (improvement) in mRS at 3 months relative to baseline (infusion). 
However, 4 out of 10 patients improved by 2 grades and one patient by 3 grades, suggesting that 
the UCB therapy may further benefit ischemic stroke patients. Similarly, all patients 
demonstrated improved NIHSS from time of infusion (mean 11.2 ± 1.6; range 9-14) to 3 month 
assessment (mean 5.3±2.2; range 3-9) with a shift down (improvement) in at least 4 points (mean 
6.1±1.7; range 4-9 points), and showed improvement in activities of daily life as measured by an 
increase in points on the BI (mean 52.0±24.7; range 10-80). 

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The results from this Phase 1 study satisfy our primary endpoint by demonstrating a favorable 
safety profile for IV infusion of UCB in adult patients with ischemic stroke. Furthermore, they 
suggest that outcome measures including the mRS, NIHSS, and BI are appropriate assessment 
tools for patients with ischemic stroke. These results support a controlled and randomized Phase 
2 Study using human UCB and placebo in patients with ischemic stroke.  

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Table 3: CoBIS Phase 1 – Patient Demographic and Cell Infusion Characteristics 
Number 
Subject 
Site 
Age 
Gender 
Ethnicity 
Race 
Infusion 
Date 
Infused Cell 
Dose 
x10⁷/kg 
Number 
of days post 
stroke for 
infusion 
1 
0 101 
Duke 
University 
62 
Male 
Non Hispanic or 
Latino 
White (Non 
Hispanic) 
20-Jul-15 
1.52 
8 
2 
0 102 
Duke 
University 
69 
Male 
Non Hispanic or 
Latino 
White (Non 
Hispanic) 
28-Jul-15 
2 
9 
3 
0 103 
Duke 
University 
79 
Male 
Non Hispanic or 
Latino 
White (Non 
Hispanic) 
5-Oct-15 
1.09 
6 
4 
0 104 
Duke 
University 
47 
Male 
Non Hispanic or 
Latino 
Black/ 
African 
American 
3-Dec-15 
0.83 
7 
5 
0 105 
Duke 
University 
47 
Male 
Non Hispanic or 
Latino 
White (Non 
Hispanic) 
3-Feb-16 
0.84 
3 
6 
0 1016 
Duke 
University 
51 
Male 
Non Hispanic or 
Latino 
White (Non 
Hispanic) 
3-Mar-16 
0.9 
9 
7 
0 301 
Houston 
Methodist 
70 
Male 
Non Hispanic or 
Latino 
American 
Indian/ 
American 
Native, 
White (Non 
Hispanic) 
9-Nov-15 
3.34 
7 
8 
0 302 
Houston 
Methodist 
70 
Male 
Non Hispanic or 
Latino 
Black/ 
African 
American 
21-Jan-16 
2.78 
9 

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Number 
Subject 
Site 
Age 
Gender 
Ethnicity 
Race 
Infusion 
Date 
Infused Cell 
Dose 
x10⁷/kg 
Number 
of days post 
stroke for 
infusion 
9 
0 303 
Houston 
Methodist 
75 
Male 
Non Hispanic or 
Latino 
White (Non 
Hispanic) 
23-Jan-16 
3.16 
7 
10 
0 304 
Houston 
Methodist 
45 
Male 
Non Hispanic or 
Latino 
Black/ 
African 
American 
25-Jan-16 
1.56 
5 
 
 

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Table 4: CoBIS Phase 1 – Outcomes and Adverse Events 
  
  
Baseline versus 3 Month Outcomes 
All AEs 
SAE's  
Number 
Subject 
mRS 
(baseline/ 
infusion) 
mRS       
(3 months) 
NIHSS 
(baseline/ 
infusion) 
NIHSS     
(3 
months) 
BI 
(baseline/ 
infusion) 
BI         
(3 
months) 
Number 
Therapy 
related (Y/N) 
Reportable 
(Y/N) 
1 
0 101 
5 
4 
11 
7 
34* 
5 
15 
6 
N 
N 
2 
0 102 
4 
2 
11 
6 
10* 
10 
90 
0 
N/A 
N/A 
3 
0 103 
4 
2 
11 
5 
4* 
30 
85 
0 
N/A 
N/A 
4 
0 104 
4 
2 
10 
3 
3* 
20 
95 
0 
N/A 
N/A 
5 
0 105 
4 
2 
11 
3 
11* 
30 
95 
0 
N/A 
N/A 
6 
0 106 
4 
3 
10 
5 
7* 
15 
90 
2 
N/A 
N/A 
7 
0 301 
5 
4 
14 
9 
11* 
10 
25 
0 
N/A 
N/A 
8 
0 302 
5 
4 
14 
8 
15* 
0 
35 
0 
N/A 
N/A 
9 
0 303 
5 
2 
11 
3 
4* 
30 
80 
0 
N/A 
N/A 
10 
0 304 
4 
3 
9 
4 
16** 
35 
95 
0 
N/A 
N/A 
mRS, modified Rankin Scale; NIHSS, NIH Stroke Scale; BI, Barthel Index. 
* None of the adverse events related to study drug. 
** One (1) adverse event related to study drug, but it was expected and not reportable; the event resolved on the same day as onset. 
 

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1.6 
Study Rationale and Hypotheses   
The major goal of this Phase 2 study is to study the effects of allogeneic, unrelated donor, 
UCB IV infusion in patients following ischemic stroke. Magnetic resonance imaging 
(MRI) will be used to confirm ischemic stroke in the middle cerebral artery (MCA) 
distribution. Various clinical assessments and outcome measures will be used to evaluate 
neurological and physical function and functional outcomes. The rationale for this study 
proposes: 
• The brain exhibits plasticity with the ability to recover from injuries due to stroke.  
• Cellular therapy using UCB may facilitate repair of damaged areas of the brain 
through paracrine signaling. UCB cells may recruit endogenous host cells to aid 
in enhancing neural pathway connectivity restoring functional pathways damaged 
by the stroke.  
• Cellular therapy may decrease inflammation which may, in turn, limit local tissue 
damage and subsequently increase functional recovery from injury. 
To have a lasting effect on stroke symptoms, treatment with UCB cells must stimulate 
endogenous mechanisms to repair damaged neuronal pathways and ultimately permit 
formation of normal patterns leading to changes in the cognitive symptomology of stroke. 
It is important to stress that in this view, for which there is strong preclinical and clinical 
evidence, UCB cells may not be required to proliferate or persist in the recipient. Given 
that the recipients in this study with ischemic stroke will not be pre-conditioned before 
cord blood infusion and because these patients will have normal immune function prior to 
treatment, we feel it is highly unlikely that durable engraftment of stem and progenitor 
cells from the allogeneic UCB treatment will be required to contribute to any expected 
therapeutic effect. 
1.7 
Potential Risks and Benefits 
1.7.1 
Known Potential Risks 
UCB cells or placebo will be prepared and infused using SOPs that have been used in 
over 30,000 individuals worldwide. The potential risks associated with infusion of 
allogeneic UCB include infusion related reactions, transmission of infection, Graft vs. 
Host Disease (GVHD), and secondary malignancy. Infusion related reactions include 
anaphylaxis, urticaria, dyspnea, hypoxia, cough, wheezing, bronchospasm, nausea, 
vomiting, hives, fever, hypertension, hypotension, bradycardia, tachycardia, rigors, chills, 
infection, and hemoglobinuria. Symptoms of GVHD, e.g. rash or diarrhea, are unlikely 
and would not be evident until 14 to 100 days post infusion. It is expected that the cells 
will be immunologically rejected within days to weeks of administration, eliminating a 
risk of GVHD or aberrant cell proliferation post-infusion. All UCB units are screened for 

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sterility and risk of infection or genetic disease transmission and must meet donor 
eligibility screening and potency release criteria prior to banking to minimize any risks.  
1.7.2 
Known Potential Benefits 
Potential benefits of cord blood cell infusions include the possibility that the UCB cells 
may, via direct or indirect mechanisms, reduce inflammation and also induce 
neurogenesis and other processes in the brain that decrease the impact of tissue damage 
resulting in improved mental and physical function thereby improving the quality of life 
for the participant and their families following stroke. 
2 
OBJECTIVES AND PURPOSE 
The primary purpose of this Phase 2 study is to determine whether IV infusion of banked 
allogeneic umbilical cord blood (UCB) improves functional outcome in patients with 
acute ischemic stroke in addition to best medical therapy. The study is designed to 
determine whether a single dose of UCB administered to patients within 3 to 10 days 
following acute ischemic stroke increases the probability of improved functional 
outcomes as compared to placebo therapy. Improved functional outcome will be 
measured by the shift in mRS performed at 90 days following stroke. Patients will not be 
pre-treated with immunosuppressive drugs, and each cord blood unit (CBU) will be 
obtained from an accredited U.S. public cord bank and selected based on blood type and 
cell dose, targeting a dose range of 0.5–5 x 107 total nucleated cell count (TNCC)/kg.  
2.1 
Primary Objective 
The primary objective is to determine, in a randomized, placebo controlled trial, the 
efficacy of a single IV infusion of unrelated donor UCB for improving functional 
outcomes in patients with ischemic stroke. 
2.2 
Secondary Objectives 
The secondary objectives are as follows: 
1. To describe the safety and tolerability of a single IV infusion of unrelated donor 
UCB in patients with ischemic stroke 
2. To evaluate the efficacy of a single IV infusion of unrelated donor UCB for 
improvement of neurological symptoms following ischemic stroke 
3. To evaluate the efficacy of a single IV infusion of unrelated donor UCB for 
improvement in quality of life and emotional and cognitive status in patients with 
ischemic stroke 

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2.3 
Exploratory Objectives 
To determine whether biomarkers of brain inflammation, neuronal injury, and repair, 
are differentially expressed as a function of UCB administration in addition to 
apolipoprotein E (APOE) genotype. 
2.4 
Study Endpoints 
2.4.1 
Primary Endpoint 
The primary endpoint is the shift in modified Rankin Scale (mRS) from baseline to 3 
months post infusion.  
2.4.2 
Secondary Endpoints 
1. Safety and tolerability of donor UCB infusion in adults with ischemic stroke will 
be assessed by the following:  
a. Incidence and severity of infusion reactions 
b. Incidence and severity of product-related infections 
c. Evidence of alloimmunization via anti-HLA and anti-RBC 
antibodies and nonspecific markers of systemic inflammation 
(ESR, CRP) 
d. Incidence and severity of graft vs. host disease 
e. Incidence and severity of unexpected AEs, by relation to study 
product 
f. Mortality 
2. Functional independence at 90 days defined as a 90-day mRS score of 0, 1, or 2 
3. mRS shift score at 30 and 180 days post infusion 
4. The National Institutes of Health Stroke Scale (NIHSS) at 90 days 
5. The Barthel Index (BI) at 90 days 
6. Stroke Impact Scale-16 (SIS-16) at 90 days 
7. The European Quality of Life (EQ-5D-3L) survey at 90 days 
8. Patient Health Questionnaire Scale (PHQ-8) at 90 days 
9. Telephone Interview for Cognitive Status (TICS) total score at 30 and 365 days 

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10. Stroke Inventory Test Battery scores at 90 days 
2.4.3 
Exploratory Endpoints 
1. Inflammatory cytokines and other biomarkers of brain injury and repair (e.g., 
S100B, TNFα, IL 1β, IL-4 and IL-10, VEGF, BDNF, MMP9) in peripheral blood 
at baseline, within 6-24 hours after UCB infusion, and 90 days 
2.5 
Description of Outcome Measures 
2.5.1 
Primary Outcome Measure 
Mental and physical function will be assessed by the following:  
2.5.1.1 
Modified Rankin Scale (mRS) 
The mRS is a commonly used scale for measuring the degree of disability or dependence 
in the daily activities of people who have suffered a stroke, and it has become the most 
widely used clinical outcome measure for stroke clinical trials. The mRS is scored from 0 
to 6, and describes a clinically relevant continuum from perfect health without symptoms 
(0) to death (6).57,63 Administration of the mRS takes approximately 5 minutes.  
All study personnel performing the mRS must have current certification.  
2.5.2 
Secondary Outcome Measures 
2.5.2.1 
Safety Assessments 
Safety will be assessed by documenting the frequency and severity of AEs occurring 
within 24 hours of cord blood infusion and within the 12-month period post infusion.  
2.5.2.2 
National Institutes of Health Stroke Scale (NIHSS) 
The NIHSS is a common method used by neurologists, nurses, and other medical 
professionals to determine the level of neurological impairment created by a stroke. The 
NIHSS is a 15-item neurologic examination stroke scale used to evaluate the effect of 
acute cerebral infarction on the levels of consciousness, language, neglect, visual-field 
loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.64 A 
trained observer rates the patient’s ability to answer questions and perform activities. 
Ratings for each item are scored with 3 to 5 grades with 0 as normal, and there is an 
allowance for untestable items. A patient with a completely normal neurological exam 
and normal mental status will have an NIHSS of 0. The maximum recordable NIHSS 
score is 42. The NIHSS can be administered in less than 10 minutes and should be 
administered by the same currently trained and experienced personnel throughout the 
study.  

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2.5.2.3 
The Barthel Index (BI) 
The BI is a standard measure of disability, widely used in the assessment of patients with 
stroke. The 10-item scale covers activities involving self-care (feeding, grooming, 
dressing), ability to use the bathroom, and acts of mobility. The maximum score is 100 
with a higher score reflecting greater independence in the patient. Administration of the 
BI takes 5 minutes.65  
2.5.2.4 
European Quality of Life (EQ-5D-3L) 
The European Quality of Life (EQ-5D-3L) is a standardized measure of health status 
developed by the EuroQoL Group in order to provide a simple, generic measure of health 
for clinical and economic appraisal.66 The assessment comprises the following 5 
dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. 
Each dimension has 3 levels: no problems, some problems, severe problems. The 
EuroQoL visual analogue scale (EQ VAS) records the patient’s self-rated health on a 
visual analogue scale where the endpoints are labeled ‘Best imaginable health state’ and 
‘Worst imaginable health state’. The EQ-5D-3L takes less than 5 minutes to complete. A 
proxy (spouse, family member, or caregiver) is allowed to assist the subject if they are 
unable to complete the survey alone.   
2.5.2.5 
Patient Health Questionnaire Scale (PHQ-8) 
The PHQ-8 is an eight-item questionnaire depression scale established as a valid 
diagnostic and severity measure for depression disorders including stroke. The 
questionnaire takes approximately 2 min.67  
2.5.2.6 
Stroke Impact Scale–16 (SIS-16) 
The Stroke Impact Scale–16 (SIS-16) is a composite measure of physical function 
developed by Rasch analysis from the 4 physical domains of the SIS: strength, activities 
of daily living/instrumental activities of daily living (ADL/ IADL), mobility, and hand 
function.68  It is designed to measure the impact of physical function on disability after 
stroke. The SIS-16 is a valid and reliable measure tool and because of a less pronounced 
ceiling effect, it is more sensitive to change than the BI and the Short Form-36. The SIS-
16 takes less than 10 minutes to complete. 
2.5.2.7 
Telephone Interview for Cognitive Status (TICS) 
The Telephone Interview for Cognitive Status™ (TICS™) is a brief, standardized test of 
cognitive functioning that was developed for use in situations where in person cognitive 
screening is impractical or inefficient (e.g., large-scale population screening, 
epidemiological surveys, with patients who are unable to appear in person for clinical 
follow-up).69 Although the TICS is designed to be administered using the telephone, it 
also may be administered face-to-face. Because it does not require vision, the TICS is 

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particularly useful for examining visually impaired individuals and individuals who are 
unable to read or write. Research has demonstrated that psychological data obtained over 
the telephone are as reliable and valid as those obtained through face-to-face interaction. 
The TICS correlates highly with the Mini-Mental® State Examination (MMSE®). It has 
high test-retest reliability and excellent sensitivity and specificity for the detection of 
cognitive impairment. The 11 test items usually take less than 10 minutes to administer 
and score.  
 
All examinee responses are recorded verbatim. If a patient is aphasic BUT capable of 
writing answers which in turn can be communicated over the phone to the CRC by test 
proctor then the TICS may be administered and responses accepted. For TICS questions 
that require speech (e.g., Repeat after me ‘no ifs, ands or buts’ and ‘Methodist 
Episcopal’) patient will score 0 points. If a patient is aphasic and unable to communicate 
via voice OR by writing answers then the TICS should be left blank. CRC’s should 
include an explanation such as “patient unable to participate due to aphasia and/or 
inability to write responses”. 
 
The individual item scores are summed to obtain the TICS Total score. The TICS Total 
score provides a measure of global cognitive functioning and can be used to monitor 
changes in cognitive functioning over time. The impairment ranges have been shown to 
adequately distinguish between normal participants and patients with cognitive 
impairment. The appropriate normative reference group for interpretation will depend on 
the reason for the evaluation and on the examinee's age and level of education.  
2.5.2.8 
Stroke Inventory Test Battery (SITB) 
This abbreviated neuropsychological test battery utilizes objective measures that are 
sensitive to cognitive dysfunction, with an emphasis on tests sensitive to deficits in 
learning and recall and of executive control. The test battery utilizes most measures from 
the Stroke Common Data Elements (CDEs).70 Stroke cognitive CDEs were specifically 
selected to be sensitive indicators of cognition in stroke. Individuals administering these 
tests will first be trained by a board certified clinical neuropsychologist.  
Trail Making Test71,72 The first part of this test, Trails A, requires the patient to rapidly sequence 
a straightforward series. The second part, Trails B, is a more difficult cognitive flexibility task 
requiring the patient to follow a sequential pattern while shifting cognitive sets. Trails A and B 
together take approximately 15 min to perform. 
Montreal Cognitive Assessment (MoCA)73  The Montreal Cognitive Assessment (MoCA) was 
designed as a rapid screening instrument for mild cognitive dysfunction. It assesses different 
cognitive domains: attention and concentration, executive functions, memory, language, 
visuoconstructional skills, conceptual thinking, calculations, and orientation. Time to administer 
the MoCA is approximately 10 minutes. The total possible score is 30 points; a score of 26 or 
above is considered normal.  

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Hopkins Verbal Learning Test-Revised (HVLT-R)74 The HVLT-R is a brief assessment of verbal 
learning and memory (recognition and recall) for individuals 16 years and older. It is easy to 
administer and score and is well tolerated even by significantly impaired individuals. The 
HVLT-R requires recall of a series of 12 words over three learning trials, free recall after a delay, 
and a recognition trial. The assessment takes approximately 5-10 minutes with a 25-minute delay 
to complete.  
Patient Health Questionnaire (PHQ-8) (see above) 
Short Form 36 Health Survey (SF-36)75 The Short Form-36 is one of the most widely used 
generic measures of health-related quality of life and has been shown to discriminate between 
subjects with different chronic conditions and between subjects with different severity levels of 
the same disease. The survey is a structured, self-report questionnaire that the patient can 
generally complete with little or no intervention from an interviewer. However, patients with 
visual or upper extremity impairments may need to have the SF-36 administered by a trained 
interviewer. Administration time is approximately 10 minutes. 
Controlled Oral Word Association Test (COWAT)76 The COWAT is a verbal fluency test that 
measures spontaneous production of words belonging to the same category or beginning with a 
designated letter. The examination takes approximately 5 minutes.  
Oral Symbol Digit Modalities Test (SDMT)77 The oral SDMT is a neuropsychological test used 
to assess information processing speed and is a sensitive measure for identifying deficits due to 
the presence of cerebral dysfunction. 
2.5.2.9 
Rehabilitation Survey − see Appendix 1 
This is a self-reporting survey for patients to document type and frequency of 
rehabilitation services they received while on study.   
2.5.2.10 Neuroimaging 
As part of normal standard of care, MRI is typically obtained in patients with acute stroke 
within several days of presentation. The initial brain MRI imaging performed on patients 
enrolled in this study will use the routine stroke imaging protocol and imaging equipment 
particular to each institution.  
In the event that cell infusion is scheduled to be initiated >36 hours after the baseline 
brain MRI or other neuroimaging study as performed as standard of care, non-contrast 
computed tomography (CT) of the head will also be obtained within 24 hours prior to 
infusion using routine institutional scan protocol, in order to evaluate for changes in the 
volume of infarcted brain parenchyma and for complications of potential clinical 
significance such as hemorrhage or increasing mass effect.  

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3 
STUDY DESIGN 
3.1 
Study Design Overview and Duration 
This is a multicenter, placebo controlled, randomized, double-blinded Phase 2 study in 
100 patients 18-90 years of age who have sustained a recent ischemic stroke. Potential 
patients can be consented ≥ 24 hours following stroke onset (Day 1), but no later than 
10 days after the index stroke event. Treatment with UCB cells or placebo will be 
administered intravenously as a single infusion as early as 3 days after the patient’s 
stroke, but no later than 10 days after the stroke. Administration of cord blood or placebo 
will only be done after confirmation of eligibility criteria. See Figure 3 for the study flow 
chart. 
Patients will not receive immunosuppressive or myeloablative medications prior to 
infusion of the UCB cells or placebo. 
For patients randomized to active treatment, the CBUs will be selected from an 
accredited U.S. public cord bank based on blood type and a targeted cell dose ranging 
between 0.5 to 5 x 107 TNCC/kg. For patients randomized to UCB cells at a clinical site 
that has no cord blood bank, the CBUs will be shipped frozen overnight to the site. Once 
a unit is selected and available on site, the cells will be thawed, washed, tested, released 
and infused intravenously using common SOPs at all sites.  
For patients randomized to placebo, a container of diluent with the same appearance and 
odor as the CBU will be prepared so all patients, families and medical staff are blinded to 
treatment arm.  
Patients will have a baseline brain MRI and will be assessed at 1, 3, 6, and 12 months for 
functional outcomes. All patients will receive standard of care therapy at the discretion of 
the Investigator and their other providers while enrolled in this study and all patients will 
be strongly encouraged to participate in rehabilitative therapy.  

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Figure 3: Study Flow Chart 
Days Post Primary Stroke Event 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
Screen and Consent 
 
Dosing Window (Days 3-10) 
Potential subjects can be screened on the day of the primary stroke event, after 
confirmation of ischemic stroke, but neurological status must be confirmed within 24 
hours prior to infusion. Consent may be obtained ≥ 24 hours following stroke onset 
(Day 1), but no later than 10 days after the index stroke event. 
3.2 
Research Participant Selection and Withdrawal 
3.2.1 
Study Population 
100 patients ages 18-90 years old with ischemic stroke documented by MRI  
3.2.2 
Inclusion Criteria 
An individual is eligible for inclusion if all of the following apply: 
1. 18-90 years old 
2. Recent, acute, cortical, hemispheric, ischemic stroke in the MCA distribution 
without a clinically significant midline shift as detected by MRI as a DWI 
abnormality 
3. NIHSS 6-15(R) and 6-18 (L) at the time of informed consent. Subjects with a >4-
point increase of NIHSS from time of consent (worsening of score) will not be 
eligible for infusion.  
4. Patients must have a platelet count >100,000/uL, hemoglobin >8gm/dL, absolute 
lymphocyte count (ALC) ≥ 1200 for African American patients and ≥1500 for all 
other racial-ethnic groups, and WBC >2,500/uL 
OR 
Historical pre-stroke value of ALC ≥ 1200 for African American and ≥1500 for 
all other racial-ethnic groups within 6 months of stroke 

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And a post stroke ALC value of ≥ 1000, platelet count >100,000/uL, hemoglobin 
>8gm/dL and WBC >2,500/uL. 
5. Patients who received tPA or underwent endovascular reperfusion may be 
included in the study 
6. Able to provide consent to study or consent is obtained from the patient’s legal 
representative 
7. Patients of childbearing potential must practice effective contraception during the 
study, and be willing to continue contraception for at least 6 months after 
intervention so that, in the opinion of the Investigator, they will not become 
pregnant during the course of the study 
8. Is a good candidate for the trial, in the opinion of the Investigator 
9. Agrees to participate in follow-up visits 
10. ABO/Rh matched CBU(s) with a minimum of 0.5 x 107 TNCC/kg based on the 
pre-cryopreservation TNCC is available for infusion   
11. Has not had a disease or therapy that would compromise current immune 
function. 
3.2.3 
Exclusion Criteria 
An individual is ineligible to participate if any of the following apply: 
3.2.3.1 
Exclusionary Medical Conditions: 
1. Medical history of neurological or orthopedic pathology with a deficit as a 
consequence that results in a modified Rankin Scale >1 before stroke or has a 
pre-existing cognitive deficit 
2. Clinically significant and/or symptomatic hemorrhage associated with stroke 
3. Evidence of significant midline shift as assessed by CT or MRI who are felt to be 
at high risk for neurological decompensation or need for decompressive 
hemicraniectomy due to hemispheric edema  
4. New intracranial hemorrhage, edema, or mass effect that may place patient at 
increased risk for secondary deterioration when assessed prior to infusion 
5. Hypotension as defined as the need for IV pressor support of SBP <90 
6. Isolated brain stem stroke 
7. Pure lacunar stroke 

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8. Requires mechanical ventilation. An exception may be patients who were 
electively intubated for endovascular reperfusion and then extubated immediately 
following the procedure. 
9. Requires a craniotomy 
10. Serious psychiatric or neurological disease which could alter evaluation on 
functional or cognitive scales 
11. Active systemic infection that is felt, at the discretion of the Investigator, to place 
the patient at increased risk for participation in this study 
12. Documentation of human immunodeficiency virus positive (HIV+) status in the 
medical record 
13. Active malignancy within 3 years prior to the start of screening excluding skin 
cancers other than melanoma  
14.  Known hypercoagulable state or coagulopathy deficiencies such as Factor V 
Leiden, Antiphospholipid Syndrome (APC), Protein C, Protein S, anticardiolipin 
antibody, phospholipid syndrome or Sickle Cell Disease 
15. History of or currently active autoimmune disease, or current immunomodulatory 
therapy or a recipient of immunomodulatory therapy in the past year. 
16. Concurrent illness or condition that in the opinion of the Investigator might 
interfere with treatment or evaluation of safety  
17. Current or recent history of alcohol or drug abuse, or stroke associated with drug 
abuse that Investigator feels may impair therapy or assessments 
18. Pregnant as documented by blood test or lactating  
3.2.3.2 
Prohibited Concomitant or Prior Therapies 
1. Patients currently receiving immunosuppressant drugs, not including 
glucocorticoid taper, topical/inhaled glucocorticoids 
2. History of prior transfusion reaction 
3. Currently on dialysis 
4. Recipient of bone marrow or organ transplant 
5. Renal insufficiency with serum creatinine > 2.0 mg/dL 

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6. Hepatic insufficiency (bilirubin >2.5mg/dL or transaminases >5x the ULN) 
Patients with Gilberts syndrome are eligible for the study if other liver function 
tests are normal, regardless of bilirubin level 
7. Previous or current treatment with angiogenic growth factors, cytokines, gene or 
stem cell therapy 
8. Participating in another interventional clinical trial of an investigational therapy 
within 30 days of consent 
3.3 
Early Withdrawal of Research Participants 
The following criteria will be used for removal from protocol therapy:  
• Diagnosis of a genetic disease while under evaluation or on study 
• Significant change in medication and therapy as determined by the PI 
• Change in medical condition that precludes study participation 
3.3.1 
Off-study Criteria 
Patients who are off protocol therapy are to be followed for the duration of the study or 
until they meet off-study criteria as below: 
• Death 
• Lost to follow-up 
• Withdrawal of consent for any further data collection 
4 
STUDY PRODUCT 
4.1 
Allogeneic Umbilical Cord Blood 
Patient enrollment will be dependent on the availability of adequately dosed ABO/Rh 
matched banked CBUs that have been stored at an accredited U.S. public cord bank. The 
unit must meet donor screening and product characterization as detailed below.  
4.2 
Selection of Allogeneic Cord Blood Units   
CBUs will be selected based on blood type and the number of cells in the 
pre-cryopreservation product, targeting a dose range of 0.5 to 5 x 107 TNCC/kg. 
Screening of maternal blood collected within 7 days before or after delivery is used for 
cord blood donor infectious disease screening. Maternal blood testing must have been 

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performed in a Clinical Laboratory Improvement Amendments (CLIA) certified donor-
testing laboratory and must include the following:   
• Hepatitis B surface antigen 
• Hepatitis C antibody 
• HIV-1 and HIV-2 antibodies 
• Human T cell lymphotropic virus (HTLV)-I and HTLV-II antibodies 
• Cytomegalovirus (CMV) 
• Syphilis 
Additional screening, which is dependent on the timing of the cord blood collection, may 
include nucleic acid testing (NAT) for HIV, hepatitis C virus (HCV), hepatitis B virus 
(HBV), West Nile Virus, and serological testing for Chagas Disease. The donor mother 
must screen negative for all tests, except for CMV or hepatitis B core antibody 
(anti-HBc). Units from mothers who test positive for anti-HBc but who test negative for 
HBsAg and HBV NAT may be used. Records for maternal testing are reviewed at the 
cord blood bank prior to release of the unit for treatment. In addition, for recently banked 
units, donor screening, through the medical history, for Zika virus is performed. 
4.3 
Cord Blood Unit Characterization Pre-cryopreservation and after Thawing 
Results of initial testing at the cord blood bank must meet the following criteria to be 
acceptable for administration to study patients: 
• Pre-cryopreservation TNCC ≥ 0.5x107/kg patient weight 
• Viability of CD34+ cells ≥ 70% after thawing 
• Pre-cryopreservation sterility culture with no growth 
All cells recovered post-thaw will be infused.  
On the day of infusion, the cord blood will be thawed and washed in an automated 
fashion using the Sepax device. If able, ABO will be measured after thawing to cross-
check pre- cryopreservation data prior to infusion. The cells will be resuspended into 
dextran 40 + 5% human serum albumin. The final volume of the cellular product to be 
infused will be 50 +/- 5 mL delivered to the clinic in a Sepax or transfer bag. 
Post processing of the CBU, a sample will be removed for standard studies including 
TNCC, viable CD34+ cell count, confirmatory HLA type, cell viability, Colony Forming 

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Units (CFU), and sterility cultures to be performed in the Stem Cell Laboratory or by a 
selected CLIA certified laboratory. This data will not be available prior to infusion.  A 
residual sample of the UCB will be retained for potential future testing. 
4.4 
Preparation of Placebo 
In order for the patients, family, and medical staff to be truly blinded to the type of 
infusion they are receiving, the placebo product must be similar in both appearance and 
odor. Therefore, the placebo product will be acellular and will consist of tissue culture 
medium 199 (TC-199 [pink]) with 1% dimethyl sulfoxide (DMSO), which are standard 
components in cellular products. The volume of placebo product will be 50 +/- 5 mL, 
which is in the range of a typical UCB unit that has been washed and thawed after 
cryopreservation. The 50 +/- 5 mL of placebo solution to be infused will be delivered to 
the clinic in a Sepax or transfer bag matching the final container used for the suspended 
UCB cells, so that the clinical staff remains blinded to study product or placebo. 
4.5 
Transport of Study Product  
All study products will be transported from the laboratory to the bedside for infusion in a 
validated container to maintain room temperature. Once thawed and washed, the cells or 
placebo have an expiry of 6 hours at room temperature. 
4.6 
Administration of Allogeneic Umbilical Cord Blood or Placebo 
On the day of infusion, a peripheral IV will be placed by the patient’s care team if venous 
access has not been previously established.  
Premedication for the cord blood or placebo infusion will be administered 30-60 minutes 
prior to the start of the infusion. Premedication with diphenhydramine 0.5mg/kg/dose IV 
(maximum 50 mg), hydrocortisone 1mg/kg /dose IV (maximum 100 mg), and 
acetaminophen 10-15mg/kg (maximum 650 mg orally [PO] or per rectum [PR]) will be 
administered.  Antihypertensive medication may be advised for hypertensive patients or 
made available if needed in a timely manner, in light of the risk that premedications, 
specifically hydrocortisone, as well as residual DMSO in the cell product may contribute 
to elevation in blood pressure. Staff caring for the patient and the patient’s family should 
be aware that residual DMSO in the UCB product often causes a temporary notable odor 
in patients’ breath and from their skin for up to 24 hours post infusion. 
The allogeneic cord blood will be administered intravenously over 5 to 30 minutes not 
exceeding a maximum of 5 mL/kg/hr; administration will be under direct physician 
supervision for the duration of infusion. The infusion rate will be reduced if the fluid load 
is not tolerated. Vital signs (heart rate, blood pressure, temperature, respiratory rate, pulse 
oximetry) will be checked before the infusion, every 5 minutes during the infusion, at the 

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end of the infusion, then as scheduled in MOP-01 until 4 hours post infusion. Patients 
will be observed for at least 4 hours post infusion and receive IV hydration for a 
minimum of 2 hours post infusion. Hydration will consist of normal saline (0.9% NS) 
infused at a minimum of 75 ml/hr. If the patient is receiving at least this rate of hydration 
(NS or other fluid) as part of their clinical care, no additional fluids will be given. 
If the patient is discharged before 24 hours have passed since the start of infusion, there 
will be a phone call or observation by the study staff within 24 hours after discharge to 
document AEs or any change in status.  
4.7 
Care During Unexpected Events 
In the event that a patient develops signs or symptoms of allergic reaction or anaphylaxis 
including urticaria, difficulty breathing, cough, wheezing, or vomiting during their 
infusion, the infusion will be paused, slowed, or terminated. Mild reactions may be 
treated with additional diphenhydramine, solumedrol, and/or inhaled albuterol. Other 
medications may be given as clinically indicated by the patient’s physician.   
If a patient has evidence of illness on the day of planned infusion, including but not 
limited to fever >38.1° C (100.5°F), active infection, progressive rash, vomiting, 
diarrhea, or respiratory distress, the infusion will be postponed. If the temperature drops 
and patient stabilizes to 38.1° C (100.5°F) and remains no higher than this for 24 hours, 
then the infusion may proceed as planned. 
5 
STUDY PLAN 
5.1 
Schedule of Procedures and Assessments 
The schedule of study procedures and assessments is summarized in Table 5: 
 

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Table 5: Schedule of Study Procedures and Assessments 
 
Between Day 1 and 
Day 10 
Between Day 3 and 
Day 10 
Post Infusion 
Screening 
Day of Infusion 
24 hours 
 
Phone or 
Visit 
30 days  
±7 days 
Phone or 
Visit 
90 days 
±14 days 
Visit at 
Clinic/Site 
6 month 
±14 days 
Phone call 
12 month 
±14 days 
Phone 
call 
Consent  
Xa 
Eligibility  
X 
Medical History/ Stroke 
History 
X 
X 
 
 
 
 
 
Physical/  
Neurological exam  
 
Xb 
Xb (before premeds) 
X b 
X 
Vital Signs 
 
X 
 
 
 
 
 
Brain MRI or CT  
X c 
X c 
Laboratory Testing  
X d 
X e  
Buccal swab 
X f 
 
 
 
 
 
 
Research Blood Samples 
 
Xg,h,i 
Xg,j 
 
X g 
 
 
Serum pregnancy test  
 
X k  
 
 
 
 
 
Pre-medications 
 
X (30-60 minutes prior 
to infusion) 
 
 
 
 
 
Infusion of UCB or placebo 
 
X 
 
 
 
 
 
IV hydration 
 
X 
 
 
 
 
 
NIHSS 
X (daily until infusion) 
X (before premeds and 
post infusion) 
Xl 
 
X 
 
 
mRS 
X (historical) 
X (prior to infusion) 
X 
X 
X 
X 
BI 
 
 
 
X 
X 
X 
X 
EQ-5D-3L 
 
 
 
 
X 
X 
X 
SIS-16 
X 
X 
X 
X 
TICS  
 
 
 
X 
 
X 
X 

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Between Day 1 and 
Day 10 
Between Day 3 and 
Day 10 
Post Infusion 
Screening 
Day of Infusion 
24 hours 
 
Phone or 
Visit 
30 days  
±7 days 
Phone or 
Visit 
90 days 
±14 days 
Visit at 
Clinic/Site 
6 month 
±14 days 
Phone call 
12 month 
±14 days 
Phone 
call 
PHQ-8 
X 
X 
X 
Survey on post-stroke rehab  
X 
X 
X 
X 
Stroke Inventory Test Battery 
Trail Making Test 
X 
MoCA 
X 
COWAT 
X 
HVLT-R 
X 
Oral SDMT 
X 
SF-36 
X 
PHQ-8 
X 
Safety questionnaire 
 
 
X 
X 
X 
X 
X 
Adverse events 
X 
Xh 
X 
X 
X 
X 
X 
Concomitant medications 
X 
Xh 
X 
X 
X 
X 
X 
a Potential subjects can be screened on the day of the primary stroke event, after confirmation of ischemic stroke, but neurological status must be confirmed within 24 
hours prior to infusion. Consent may be obtained ≥ 24 hours following stroke onset (Day 1), but no later than 10 days after the index stroke event.” 
b Neurological exam is conducted prior to administration of premeds and pre- and post-infusion on the day of infusion. If subject is discharged less than 24 hours post 
infusion, the physical and neurological exam should be performed after administration of post-infusion fluids but prior to discharge.  
c Clinical or diagnostic MRI results can be used. CT scan of the brain must be performed within 24h before infusion if brain MRI was not completed within 36h prior to 
infusion. 
d Infectious disease panel, CBC and differential, lipid profile, coag panel, HLA typing, serum chemistries, troponin, liver function tests, ABO/Rh typing, direct and 
indirect Coombs, ESR, CRP and HLA antibody screen (PRA). For HLA typing being sent to MD Anderson, use 2 x 10 mL EDTA (lavender) tube and 1 x 10 ml ACD 
(yellow) tube. 
e HLA antibody screen (PRA), ESR, CRP, direct and indirect Coombs. If any of these tests have been done within 2 days, those results can be used for the purpose of 
this study.  
f Apolipoprotein E (APOE) genotyping (voluntary) will be performed on a buccal swab sample collected during screening or at any time prior to hospital discharge or at 
90 day visit 
g Collection of blood for research.  
h Before administration of premeds. 

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i Within 24 h prior to start of infusion. 
j Within 6-24 h of completing infusion.         
k Within 48 hours prior to infusion for women of child bearing potential. 
l NIHSS should be done 24 hours post infusion and daily post infusion for 7 days or until discharge.  

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5.2 
Patient Interview 
Patients who are potentially eligible to participate in the study or their legally authorized 
representatives (LARs) will be interviewed by study personnel who are trained to 
describe the study, schedule of visits, verify basic eligibility criteria, answer questions, 
and confirm interest in participation. If the patient and/or the patient’s LAR are interested 
and the patient appears to be eligible after initial discussions, written informed consent 
will be obtained via the informed consent process.   
5.3 
Assessment of Patient Capacity to Consent: 
Informed consent will be obtained by study staff experienced in working with stroke 
patients. The Investigator will clinically assess whether or not a patient will be able to 
provide legally effective informed consent at enrollment. A physician will be at every 
study visit to re-evaluate the patient’s capacity to consent. For patients who are not able 
to give consent, a LAR must sign on the patient’s behalf. In such cases, the patient will be 
informed of his or her enrollment in the study when he or she has become fully alert: the 
patient will be told who gave surrogate consent and that the patient has the right to 
withdraw from the study. The patient will be asked to sign the consent form at that time.  
5.4 
Screening, Consent, Study Visits and Follow-up Phone Calls 
5.4.1 
Screening and Consent (Day 1-10) 
• 
Potential subjects can be screened on the day of the primary stroke event, after 
confirmation of ischemic stroke, but neurological status must be confirmed within 
24 hours prior to infusion. Consent may be obtained ≥ 24 hours following stroke 
onset (Day 1), but no later than 10 days after the index stroke event. 
• 
Medical/Stroke History  
• 
Physical / Neurological exam 
• 
MRI: A standard of care MRI may be used if it was performed within 36 hours 
prior to infusion. If an MRI was not performed within 36 hours prior to infusion, a 
CT must be done within 24 hours prior to infusion. 
• 
Laboratory Tests: The laboratory tests listed below should be collected within 48 
hours of screening. Exceptions include the ABO/Rh typing, lipid profile, 
coagulation panel, CBC and differential, and troponin; if these were performed as 
standard of care upon admission, the results can be used for screening, even if they 
are greater than 48 hours old. 
-CBC and differential  
-ABO/Rh typing 

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-Lipid Profile (total cholesterol, triglycerides, HDL, LDL) 
-Coagulation Panel (PT/INR, PTT)  
-HLA typing  
-Serum Chemistries (sodium, potassium, chloride, bicarbonate, urea 
      nitrogen (BUN), creatinine, glucose, calcium, troponin) 
-Liver Function Tests (AST, ALT, alkaline phosphatase, total bilirubin, total 
      protein, albumin) 
-Direct and Indirect Coombs 
-HLA antibody screen (Panel Reactive Antibody [PRA]), ESR, and CRP 
• 
Infectious disease screening panel performed in an FDA approved, CLIA certified 
laboratory:  Hepatitis B Surface Antigen, Antibody to Hepatitis C Virus, Antibody 
to Human Immunodeficiency Virus Types 1 and 2, Antibody to Hepatitis B Core 
Antigen, Antibody to Human T-lymphotropic Virus Types I and II, Trypanosoma 
cruzi, Antibody to Treponema pallidum (syphilis), Antibody to Cytomegalovirus, 
HIV-1/HCV/HBV NAT (nucleic acid test), West Nile Virus NAT  
• 
(Optional) Buccal swab collected for APOE genotyping at screening, prior to 
hospital discharge or at 90-day visit. 
• 
NIHSS should be performed daily beginning the day of consent through the day of 
infusion (prior to infusion of the UCB cells or placebo), within 24 hours of 
administration of post-infusion fluids, and for up to 7 days post-infusion or until 
discharge.  
• 
mRS (historical) 
• 
AEs 
• 
Concomitant meds 
5.4.2 
Day of Infusion (Day 3-10) 
• 
Review of labs (pre-infusion).  
Results of labs related to the inclusion/exclusion criteria should be reviewed by the 
study staff to verify that the subject remains qualified for the study prior to infusion. 
Results for the HLA typing, infectious disease panel, direct and indirect Coombs, 
ESR, CRP and HLA antibody screen do not need to be final prior to infusion. In 
addition, clinical labs should be reviewed by the PI or designee in order to establish 
that there are no contraindications to infusion of the cord blood. 
• 
Medical / Stroke History and brief physical exam (pre-infusion before pre-meds) 
• 
Neurological/Physical Exams (before pre-meds) 
Neurological/physical exam is conducted prior to administration of premeds and 
pre- and post-infusion for day of infusion. If subject is to be discharged less than 24 

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hours post infusion, the physical and neurological exam should be performed after 
administration of post-infusion fluids but prior to discharge.  
• 
CT scan should be performed within 24 hours pre-infusion if MRI is not performed 
within 36 hours of infusion  
• 
(Optional) Collection of research blood samples for biomarkers/immuno-panel 
analysis within 24 hours prior to infusion 
• 
Serum pregnancy test pre-infusion for women of childbearing potential 
• 
Administration of pre-meds 30-60 minutes prior to the start of the infusion. 
Premedication consists of diphenhydramine 0.5mg/kg/dose IV (maximum 50 mg), 
hydrocortisone 1mg/kg /dose IV (maximum 100 mg), and acetaminophen 10-
15mg/kg (maximum 650 mg orally [PO] or per rectum [PR]).  Antihypertensives 
may be administered if clinically indicated or should be made available if needed in 
a timely manner. 
• 
Infusion of study product with cardiac-respiratory hemodynamic monitoring and 
vital signs (temperature, heart rate, respiratory rate, blood pressure, pulse oximetry) 
pre-infusion, every 5 minutes during the infusion, at the end of the infusion, and as 
scheduled in MOP-01 until 4 hours post infusion 
• 
Patients will be treated with standard IV hydration for a minimum of 2 hours post 
infusion.  
• 
Assessments:    
− 
mRS, NIHSS (prior to start of infusion and administration of pre-meds) 
− 
If on the day of infusion NIHSS is <6, patient remains eligible for infusion 
− 
Subjects with >4-point increase of NIHSS from time of consent (worsening 
of score) will not be eligible for infusion. 
− 
NIHSS (within 24 hours after administration of post-infusion fluids) 
− 
Neurological and physical exam (before pre-meds and infusion and post 
infusion) 
− 
AEs, Concomitant meds (post infusion), safety questionnaire 
5.4.3 
Follow-up phone call or visit 24-hour post infusion 
• 
Physical/Neurological exam (if visit) 
• 
(Optional) Collection of research blood samples for biomarkers/immuno-panel 
analysis within 6-24 hours of completing infusion. If patient is discharged prior to 
this time no blood will be collected.  

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• 
If the subject is discharged on the day of infusion, then a physical exam and 
neurological exam should be performed after infusion and fluid administration but 
prior to discharge. 
• 
NIHSS should be done within 24 hours of administration of post-infusion fluids and 
daily for 7 days post-infusion or until discharge.  
• 
AEs, Concomitant meds 
5.4.4 
Follow-Up Phone Call or Visit (Day 30 ± 7 days) 
• 
Assessments: mRS, BI, SIS-16, TICS Survey on Post-stroke Rehabilitation 
• 
Safety questionnaire, AEs, Concomitant meds 
5.4.5 
Visit 1 – 90 Days Post Infusion (± 14 days) 
• 
Physical/ Neurological exam 
• 
Laboratory Tests: HLA antibody screen (PRA), ESR, CRP, direct and indirect 
Coombs  
• 
Collection of research blood samples for biomarkers/immuno-panel analysis 
• 
Assessments: mRS, NIHSS, BI, EQ-5D-3L, SIS-16, PHQ-8, Survey on Post-Stroke 
Rehabilitation, Stroke Inventory Test Battery (SITB)  
• 
Survey on Post-stroke Rehabilitation 
• 
Safety questionnaire, AEs, Concomitant meds 
5.4.6 
Follow-up phone call (6 months ±14 days)  
• 
Assessments: mRS, BI, SIS-16, EQ-5D-3L, PHQ-8, TICS 
• 
Survey on Post-stroke Rehabilitation 
• 
Safety questionnaire, AEs, Concomitant meds 
5.4.7 
Follow-up phone call (12 months ±14 days) 
• 
Assessments: mRS, BI, EQ-5D-3L, SIS-16, PHQ-8, TICS 
• 
Survey on Post-stroke Rehabilitation 
• 
Safety questionnaire, AEs, Concomitant meds 

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6 
STATISTICAL CONSIDERATIONS 
6.1 
Accrual 
It is estimated that up to 6 research participants will be enrolled each month at each of the 
6 centers and that approximately 20-24 months of accrual will be necessary to enroll 
100 patients.  
6.2 
Study Duration 
Research participants will be followed for 12 months after the administration of allogeneic cord 
blood. 
6.3 
Demographics and Baseline Characteristics 
The number of patients completed and discontinued early from study, and the reasons for 
discontinuation, will be summarized, if applicable. Demographics and baseline characteristics to 
include age, gender, and race/ethnicity and baseline status as measured by the mental and 
physical assessments will be summarized for all patients. 
6.4 
Description of the Primary Efficacy Outcome Measure 
The mRS is a commonly used scale for measuring the degree of disability or dependence in the 
daily activities of people who have suffered a stroke, and it has become the most widely used 
clinical outcome measure for stroke clinical trials. The mRS is scored from 0 to 6, running from 
perfect health without symptoms (0) to death (6)57,63 Administration of the mRS takes 5 minutes. 
Personnel performing the mRS must have current certification. 
The mRS is: 
0 - No symptoms. 
1 - No significant disability. Able to carry out all usual activities, despite some 
symptoms. 
2 - Slight disability. Able to look after own affairs without assistance, but unable 
to carry out all previous activities. 
3 - Moderate disability. Requires some help, but able to walk unassisted. 
4 - Moderately severe disability. Unable to attend to own bodily needs without 
assistance, and unable to walk unassisted. 
5 - Severe disability. Requires constant nursing care and attention, bedridden, 
incontinent. 

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6 - Dead. 
6.5 
Sample Size and Power Calculations 
The primary endpoint for this study is the shift in mRS from baseline to 90 days, defined 
for the i-th patient as: 
𝛿𝛿𝑖𝑖= 𝑚𝑚𝑚𝑚𝑚𝑚0 −𝑚𝑚𝑚𝑚𝑚𝑚90,
𝑖𝑖= {1. . 𝑁𝑁} 
Where 𝑚𝑚𝑚𝑚𝑚𝑚0 and 𝑚𝑚𝑚𝑚𝑚𝑚90 are the baseline and 90-day mRS scores, respectively. Since a 
shift downward in the mRS scale is considered a clinical improvement, the differences in 
𝛿𝛿𝑖𝑖 are calculated from baseline to insure that, for hypothesis testing purposes, larger shift 
values represent more clinically desirable outcomes.  
Given the above definition we can define testable hypotheses for the primary efficacy 
analysis as follows. 
(Null hypothesis) H0: P(Ti > Pi ) = P ( Pi > Ti) 
(Alternative hypothesis) HA: P(Ti > Pi ) ≠ P ( Pi > Ti) 
Where Ti and Pi are randomly selected 90-day mRS shift scores from the population of 
patients treated with cord blood (T) or placebo (P), with the differences having the form 
of 𝛿𝛿𝑖𝑖 shown above. 
The test of this hypothesis can be carried out using a 2-sample Wilcoxon rank sum test. We used 
Noether’s formula78 to approximate sample size required under various alternatives assuming a 
2:1 allocation (cord:placebo), a 5% Type I error rate, and power of 80%. The specific alternative 
hypothesis, or detectable effect size, in this case is the probability that a randomly sampled 
patient treated with cord blood has a higher (more favorable) mRS shift score (𝛿𝛿𝑖𝑖) compared with 
a randomly sampled patient treated with placebo. The probability can also be understood as an 
odds ratio (OR) comparing treatment to placebo. The following table (Table 6) illustrates sample 
sizes required to detect various effect sizes (expressed both as probabilities and ORs) assuming 
the aforementioned design parameters. 
Table 6. Sample Size Parameters 
Probability 
under 
HA 
OR 
under 
HA 
NTotal 
NPlacebo 
NTreatment 
0.55 
1.2 
1,461 
483 
978 
0.57 
1.3 
700 
231 
469 
0.58 
1.4 
429 
142 
287 

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Probability 
under 
HA 
OR 
under 
HA 
NTotal 
NPlacebo 
NTreatment 
0.60 
1.5 
295 
98 
197 
0.62 
1.6 
223 
74 
149 
0.63 
1.7 
175 
58 
117 
0.64 
1.8 
144 
48 
96 
0.66 
1.9 
123 
41 
82 
0.67 
2.0 
102 
34 
68 
 
An effect size of p=0.67 (OR=2.0) was selected for this study as it is felt to be the minimal 
clinically relevant effect size and is detectable with a reasonable sample size. The total sample 
size required is N=102 (68 on cord blood and 34 on placebo). For simplicity we round the 
number to N=100. 
Therefore, with a total sample size of N=100 (67 on cord blood and 33 on placebo), our study 
will have approximately 80% power to detect a significant difference between cord blood and 
placebo when the true probability of a greater mRS shift in cord blood patients (compared to 
placebo) is 67%. This equates to a doubling of the odds that a randomly selected patient treated 
with cord blood will have a more favorable mRS shift score compared with a randomly selected 
patient treated with placebo. These calculations assume a Type I error rate of 5%. 
6.6 
Correction for Multiple Testing 
The primary efficacy analysis will use an alpha of 0.05. Statistically significant results on the 
secondary efficacy endpoints will be identified using the False Discovery Rate (FDR) procedure. 
The primary efficacy comparison will be included in the FDR procedure. Analysis of safety 
outcomes and exploratory endpoints will be primarily descriptive and thus will not include 
correction for multiple testing. Further details are available in the Statistical Analysis Plan 
(SAP). 
6.7 
Randomization Plan 
This study will randomize participants 2:1 to cord blood or placebo and will utilize a randomly 
varying block size with stratification by study center (up to 6 centers) and NIHSS score (6–11 or 
12-18). The NIHSS score collected closest to randomization will be used.  

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6.8 
Analysis Plan 
Full details of the planned analysis are available in the accompanying SAP. Briefly, safety 
analyses will be primarily descriptive and will use graphical displays and tabulated descriptive 
statistics. The efficacy analysis for the primary endpoint is based on the normal approximation to 
a two-sample Wilcoxon rank sum test. Additional analyses are described in the SAP. 
6.8.1 
Analysis Populations (see SAP for further details): 
Full Analysis Population – This population includes all enrolled participants and is used 
for descriptive purposes; e.g. to identify patients who do not provide data for the primary 
efficacy analysis. 
Modified Intention to Treat (mITT) Population – This analysis set will include only 
patients who complete the mRS at both baseline and 90 days. Calculation of the mRS 
shift score is not possible in patients who are missing either the baseline or 90-day mRS 
evaluation. Patients will be analyzed according to the treatment they were assigned 
(regardless of what they actually receive). 
Safety Population – The safety population will include all patients who received an 
infusion. Analyses of the Safety Population will be conducted using an as-treated 
approach, which considers each patient according to the treatment actually received 
rather than the treatment they were assigned. 
6.9 
Interim Analysis 
An interim estimation of conditional power79 will be conducted when the primary endpoint is 
evaluable on approximately 50% of the participants (17 patients in the placebo group 34 in the 
cord blood group). Conditional power will be evaluated assuming future data are consistent with 
the observed trend at the time of the interim analysis as well as the planned alternative. There is 
no a priori threshold for curtailing the trial for futility. Rather, the interim analysis is intended to 
provide information to the DSMB and study sponsor to assist with determining whether the trial 
should proceed as designed, or whether the plans detailed in this protocol are realistic under 
reasonable alteration to the pre-specified sample size. The interim analysis will be accomplished 
by an independent, unblinded statistician. 
7 
SAFETY AND ADVERSE EVENT REPORTING 
7.1 
 Adverse Events 
Adverse event means any untoward medical occurrence associated with the use of the 
investigational product, whether or not considered related to the investigational product.   

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7.1.1 
Serious Adverse Events 
An adverse event or suspected adverse reaction is considered “serious” if, in the view of either 
the Investigator or sponsor, it results in any of the following outcomes: death, a life threatening 
adverse event, inpatient hospitalization or prolongation of existing hospitalization, a persistent or 
significant incapacity or substantial disruption of the ability to conduct normal life functions, or a 
congenital anomaly/birth defect. Important medical events that may not result in death, be life 
threatening, or require hospitalization may be considered serious when, based upon appropriate 
medical judgment, they may jeopardize the patient or subject and may require medical or 
surgical intervention to prevent one of the outcomes listed in this definition. 
7.1.2 
Grade/Severity 
Grade/Severity will be performed per Common Terminology Criteria for Adverse Events 
(CTCAE) guidelines. 
7.1.3 
Suspected Adverse Reaction 
Suspected adverse reaction means any adverse event for which there is a reasonable possibility 
that the investigational product caused the adverse event. ‘Reasonable possibility’ means there is 
evidence to suggest a causal relationship between the investigational product and the adverse 
event. 
7.1.4 
Causality 
The Investigator will use the following question when assessing causality of an adverse event to 
the investigational product:  Is there a reasonable possibility that the drug caused the event?  An 
affirmative answer designates the event as a suspected adverse reaction. 
7.2 
Adverse Event Reporting 
All AEs reported or observed during the study beginning at the time of the allogeneic cord blood 
infusion must be recorded and maintained in the study participant’s paper files or electronic case 
report forms. Information to be reported includes when the site became aware of the event, 
Investigator-specified assessment of severity and relationship to study therapy, whether there is 
an alternative etiology, seriousness, as well as any required treatment for evaluations, and 
outcome. In general, investigators should report AEs as diseases or syndromes whenever 
possible, instead of reporting individual component symptoms, signs, laboratory abnormalities, 
and sequelae. Severe adverse reactions (fatal or life threatening) that are unexpected and related 
will be reported to the FDA by Duke University within seven calendar days of receipt of the 
information by telephone, mail or fax, following FDA guidelines. All non-life threatening 
serious, related and unexpected AEs will be reported to the FDA via a written report within 
15 days of receipt of the information (21CFR 312.32) by Duke University. If the Principle 
Investigator assesses the event to be unrelated to the study, then the event will not require 
expedited reporting but will be included in a summary report.  

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7.3 
Serious Adverse Event Reporting 
Any protocol deviation, SAE which is directly related to the study product, or safety event that is 
reportable for any other reason should be communicated via phone or email to the protocol PIs 
with Erin Arbuckle (study coordinator) and Jessica Chapman (Duke Regulatory Affairs) also 
notified.   
 
Contact Information for Safety Reporting: 
Joanne Kurtzberg, MD: joanne.kurtzberg@duke.edu, 919-668-1100 
Daniel Laskowitz, MD: danl@neuro.duke.edu, 919-684-5650 
Erin Arbuckle: erin.arbuckle@dm.duke.edu, 919-684-3293 
Jessica Chapman, PhD: jessica.chapman@duke.edu, 919 668-7962 
 
The Principal Investigator or its representative will be responsible for telephone, mail or fax 
reporting of suspected unexpected serious adverse reactions (SUSARs) to the FDA according to 
21 CFR 312.32. The Principal Investigator or its representative will notify the FDA by 
telephone, mail or fax of any fatal or life threatening experience (expedited report) associated 
with the use of the study therapy as soon as possible but no later than 7 calendar days after 
receipt of the information. Initial notification will be followed by a written report within 15 
calendar days. For non-life threatening SUSARs, the Principal Investigator will notify the FDA 
as soon as possible, but no later than 15 days of the initial receipt of the information. All 
reportable events per Duke HRPP policies, whether at the Duke site or elsewhere, will be 
reported to the Duke IRB in accordance with HRPP and/or FDA reporting requirements. The 
Principal Investigator or Sub-Investigator is responsible for informing the Institutional Review 
Board (IRB) and Data Safety Monitoring Board (DSMB). Copies of SAE correspondence with 
all Principal Investigators or Sub-Investigators, governing authorities, ethics committees, and the 
sponsor must be submitted to Duke University for filing. 
7.4 
Eliciting Adverse Event Information 
In addition to research participant observations, AEs will be documented from any data collected 
throughout the study including clinically significant laboratory values or physical exam findings. 
7.5 
Stopping Guidelines 
Two stopping guidelines based on safety will be monitored during the duration of the study. The 
stopping guidelines will be monitored by the study personnel, and are to be used to indicate 
boundaries requiring discussion by the DSMB. Accrual will be temporarily suspended if: 
• 
Any patient experiences a grade 4-5 infusion related reaction within 24 hours 
of infusion; 
OR 

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• 
Any patient experiences a blood stream infection deemed related to the cord 
blood infusion within 6 months of infusion 
• 
Any patient develops grade III-IV GVHD within 6 months of infusion 
A consensus decision to stop the study will be made by the Investigators and the DSMB. Such a 
decision with its supporting documentation and possible future plans for the study will be 
submitted to, and discussed with, the FDA. 
7.6 
Patient Replacement 
Treatment assignments will not be replaced for patients who are not infused, lost to follow-up, or 
are discontinued from the study. However, additional patients may be randomized per decision 
of the study sponsor. 
8 
DATA SAFETY MONITORING BOARD (DSMB) 
A DSMB will be formed and charter established. Faculty of Duke University Medical Center or 
other participating clinical sites are exempted from participation on this study DSMB. Members 
of the DSMB will comprise neurologists and a physician with experience in cell therapy. A non-
voting statistician will be invited to meetings or calls as needed. The DSMB will be notified 
immediately for all SAEs directly related to study product throughout the study. A total safety 
assessment will be prepared on an annual basis and forwarded to the DSMB for review as well. 
Policies of the DSMB will be described in the DSMB charter, and signed by all members.  
9 
DATA HANDLING AND QUALITY ASSURANCE 
9.1 
Case Report Forms 
As part of the responsibilities assumed by participating in the study, the Principal Investigator or 
Sub-Investigators agree to maintain adequate case histories of the research participants treated as 
part of the research under this protocol. The Principal Investigator and Sub-Investigator agree to 
maintain accurate case report forms (CRFs) and source documentation as part of the case 
histories. RTI will supply the CRFs electronically (eCRF) through secured electronic data entry 
systems.  
9.2 
Inspection of Records 
The Principal Investigator and Sub-Investigators at all institutions involved in the study will 
permit study-related monitoring, audits, IRB review, and regulatory inspection(s) by providing 
direct access to all study records. In the event of an audit, the Principal Investigator or 

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Sub-Investigator agrees to allow the sponsor, the FDA, or other regulatory agency access to all 
study records.  
The Principal Investigator or Sub-Investigators should promptly notify the sponsor and monitor 
of any audits scheduled by any regulatory authorities and promptly forward copies of any audit 
reports received to both. 
9.3 
Study Record Retention 
The study results will be retained in the patient’s research record for six years after the study. 
Essential documents should be retained until at least two years after the last approval of a 
marketing application in an International Council on Harmonisation region and until there are no 
pending or contemplated marketing applications in an International Council on Harmonisation 
region, or at least two years have elapsed since the formal discontinuation of clinical 
development of the investigational product. These documents should be retained for a longer 
period, however, if required by the applicable regulatory requirements.  
10 ADMINISTRATIVE ASPECTS 
10.1 Confidentiality 
All laboratory specimens, evaluation forms, reports, and other records will be identified in a 
manner designed to maintain research participant confidentiality. All records will be kept in a 
secure storage area with limited access. Clinical information will not be released without the 
written permission of the research participant’s LAR except as necessary for monitoring and 
auditing. 
The Principal Investigator or Sub-Investigator and all employees and coworkers involved with 
this study may not disclose or use for any purpose other than performance of the study, any data, 
record, or other unpublished, confidential information disclosed to those individuals for the 
purpose of the study. Prior written agreement from the sponsor or its designee must be obtained 
for the disclosure of any said confidential information to other parties. 
10.2 Institutional Review Board Approval 
Federal regulations and the International Council on Harmonisation guidelines require that 
approval be obtained from an IRB prior to participation of human research participants in 
research studies. Prior to the study onset, the protocol, informed consent, any advertisement used 
to recruit study patients, and any other written information regarding this study to be provided to 
the research participant or the research participant’s LAR must be approved by the IRB. 
Documentation of all IRB approvals and of the IRB compliance with International Council on 
Harmonisation Guideline E6 will be maintained by the site and will be available for review by 
the sponsor or its designee. 

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All IRB approvals should be signed by the IRB Chairman or designee and must identify the IRB 
name and address, the clinical protocol by title and/or protocol number, and the date the approval 
and/or favorable opinion was granted. 
The Principal Investigator or Sub-Investigator is responsible for obtaining continued review of 
the clinical research at intervals not exceeding one year or otherwise specified by the IRB. The 
Principal Investigator or Sub-Investigator must supply the sponsor or its designee with written 
documentation of continued review of the clinical research. 
10.3 Modification of the Protocol 
Any changes in this research activity, except those necessary to remove an apparent, immediate 
hazard to the research participant, must be reviewed and approved by the IRB.  
10.4 Informed Consent 
A written informed consent in compliance with Part 50 of Title 21 of the Code of Federal 
Regulations (CFR) and the clinical site’s IRB shall be obtained from each research participant 
prior to entering the study or performing any unusual or non-routine procedure that involves risk 
to the research participant.   
Before recruitment and enrollment, each prospective research participant and/or his/her LAR will 
be given a full explanation of the study and be allowed to read the approved informed consent 
form. Once the Principal Investigator or Sub-Investigator is assured that the research participant/ 
LAR understands the implications of participating in the study, the research participant/ LAR 
will be asked to give consent to participate in the study by signing the informed consent form. 
The Principal Investigator or Sub-Investigator shall provide a copy of the signed informed 
consent to the research participant and/or LAR. A second original form shall be maintained in 
the research participant’s medical records at the site. 
Informed consent will be obtained by study staff experienced in working with stroke patients. 
The Investigator will clinically assess whether or not a patient will be able to provide informed 
consent at enrollment. A physician will be at every study visit to re-evaluate the patient’s 
capacity to consent. For patients who are not able to give consent, a LAR must sign on the 
patient’s behalf. In such cases, the patient will be informed of his or her enrollment in the study 
when he or she has become fully alert: the patient will be told who gave surrogate consent and 
that the patient has the right to withdraw from the study. The patient will be asked to sign the 
consent form at that time.  
10.5 Protocol Violations and Deviations 
The Principal Investigator or Sub-Investigator or designee must document and explain in the 
research participant’s source documentation any deviation from the approved protocol. The 

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Principal Investigator or Sub-Investigator may implement a deviation from, or a change of, the 
protocol to eliminate an immediate hazard to study research participants without prior IRB 
approval. As soon as possible after such an occurrence, the implemented deviation or change, the 
reasons for it, and any proposed protocol amendment(s) should be submitted to the IRB for 
review and approval, to the sponsor for agreement, and to the regulatory authorities, if required. 
A deviation from the protocol is an unintended and/or unanticipated departure from the 
procedures and/or processes approved by the IRB and agreed to by the Principal Investigator or 
Sub-Investigator. Deviations usually have an impact on individual research participants or a 
small group of research participants and do not involve inclusion/exclusion or primary endpoint 
criteria.  
A protocol violation occurs when there is nonadherence to the protocol that results in a 
significant, additional risk to the research participant; when the research participant or Principal 
Investigator or Sub-Investigator has failed to adhere to significant protocol requirements 
(inclusion/exclusion criteria) and the research participant is enrolled without prior sponsor 
approval; or when there is nonadherence to FDA regulations and/or International Council on 
Harmonisation GCP guidelines. 
Protocol violations and deviations will be documented by the clinical monitor throughout the 
course of monitoring visits. Principal Investigators or Sub-Investigators will be notified of 
violations and/or deviations in writing by the monitor. The Principal Investigator should ensure 
that the IRB is notified of all protocol violations and deviations in a timely manner as required. 
10.6 Study Reporting Requirements 
By participating in the study, the Principal Investigator or Sub-Investigator agrees to submit 
reports of SAEs according to the timeline and method outlined in the protocol. In addition, the 
Principal Investigator or Sub-Investigator agrees to submit annual reports to his/her IRB as 
appropriate. The Principal Investigator or Sub-Investigators also agree to provide Duke 
University with an adequate report shortly after completion of the Principal Investigator’s or 
Sub-Investigator’s participation in the study. 
11 Financial Obligations 
Duke University is not financially responsible for further testing/treatment of any medical 
condition that may be detected during the screening progress. In addition, in the absence of 
specific arrangements, Duke University is not financially responsible for further treatment of the 
research participant’s disease. 

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12 Study Conduct 
The Principal Investigator agrees that the study will be conducted according to the principles of 
the International Council on Harmonisation E6 Guideline on GCP and the principles of the 
World Medical Association Declaration of Helsinki. The Principal Investigator will conduct all 
aspects of this study in accordance with all national, state, and local laws or regulations. 
13 Publications 
Following completion of the study, the data may be considered for reporting at a scientific 
meeting or for publication in a scientific journal. In these cases, Duke University will be 
responsible for these activities and will work with other investigators to determine how the 
manuscript is written and edited, the number and order of authors, the publication to which it will 
be submitted, and other related issues. 
Data is the property of Duke University but data and publication thereof will not be unduly 
withheld. 
 
 
 

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14 References 
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15 Appendix  
Survey on Post-stroke Rehabilitation- Please answer three questions: 
1. Did you receive rehabilitative therapy while in the acute-care hospital? 
No 
 
 
 
Yes 
 
2. Did you receive rehabilitative therapy following discharge form the acute-care 
hospital? 
No 
 
 
Yes 
 
 
3. If yes, check the services you received since the last study visit and frequency of 
treatments:  
 
 
 
 
FREQUENCY 
 
 
 
 
               Daily 
 
 ≥ 1 X/week  
<1 X/week 
Rehabilitation Nurses 
Physical Therapists 
Occupational and recreational 
Therapists 
 
Speech-Language pathologists