Clinical trial NCT04462536
Conditions: Stroke, Acute
Sponsor: NoNO Inc.
Start date: 2020-12-06; Completion date: 2023-08-31
Enrollment: 850 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
The primary purpose of this study is to determine if a single dose of nerinetide can reduce global disability in people who have had a stroke and are selected for endovascular therapy without the use of a tissue plasminogen activator (alteplase, tenecteplase, or equivalent).

Detailed description:
This study is a Phase 3, randomized, multicentre, blinded, placebo-controlled, parallel group, single-dose with a single interim analysis. Because AIS (acute ischemic stroke) is a medical emergency, the trial is designed to enable the administration of standard-of-care treatments without delay in order to save the life of the person concerned, restore good health or alleviate suffering.

Participants harboring an acute ischemic stroke who are selected for endovascular revascularization without intravenous or intra-arterial thrombolytic therapy will be given a single, 2.6 mg/kg (up to a maximum dose of 270 mg) intravenous dose of nerinetide or placebo. Outcomes of the main trial will be evaluated throughout a 90 day observation period.

Participants will be followed at 1-Year for the analytic sub-trial for further outcome assessment by telemedicine or telephone interview conducted by individuals blinded to the outcome of the main trial. This sub-trial will be conducted to explore the independent functioning and quality of life at 1-Year.

Arms: arm 1: Vehicle only arm 2: Single intravenous infusion of nerinetide 2.6 mg/kg (up to a maximum dose of 270 mg) over 10 ± 1 minutes
Interventions: intervention 1: Placebo intervention 2: Nerinetide
Intervention descriptions: intervention 1: Vehicle only intervention 2: Single intravenous infusion of nerinetide 2.6 mg/kg (up to a maximum dose of 270 mg) over 10 ± 1 minutes

Protocol documents:
Prot_SAP_000.pdf: 
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A Multicentre, Randomized, Double-blinded, Placebo-controlled, Parallel Group, Single-
dose Design to Determine the Efficacy and Safety of Nerinetide in Participants with Acute 
Ischemic Stroke Undergoing Endovascular Thrombectomy Excluding Thrombolysis 
(ESCAPE-NEXT Trial) 
PROTOCOL NA-1-009 
Version 6.0 
DATE: 01 June 2022 
Compound: Nerinetide (NA-1) 
Coordinating Centre 
University of Calgary 
Health Authority File Number: 
EudraCT 
2020-002360-30 
US IND 
clinicaltrials.gov number 
118,087 
NCT04462536 
Foothills Medical Centre
1403 29th Street NW
Calgary, Alberta, Canada T2N 2T9
Sponsor 
NoNO Inc. 
479A Wellington Street West
Toronto, Ontario, Canada M5V 1E7


Personal Protected Data


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DOCUMENT HISTORY 
Document 
Date 
Original Protocol/Version 1.0 
30 June 2020 
Version 2.0 
07 August 2020 
Version 3.0 
20 August 2020 
Version 4.0 
26 November 2020 
Version 5.0 
18 November 2021 
Version 6.0 
01 June 2022 


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Table of Contents 
SIGNATURES OF APPROVAL ........................................................................................................................ 2 
1 PROTOCOL SUMMARY ........................................................................................................ 8 
1.1 SYNOPSIS ............................................................................................................................................. 8 
1.2 COORDINATING CENTRE AND SPONSOR.......................................................................................... 18 
2 INTRODUCTION ................................................................................................................... 19 
2.1 BACKGROUND ................................................................................................................................... 19 
2.1.1 
NERINETIDE (NA-1): A POST-SYNAPTIC DENSITY 95 INHIBITOR 
20 
2.1.2 
IMPACT OF ALTEPLASE ON NERINETIDE 
21 
2.1.3 
THROMBECTOMY AS A STROKE TREATMENT 
21 
2.1.4 
TREATMENT OF STROKE WITH NERINETIDE IN NON-HUMAN PRIMATES 
22 
2.1.5 
PREVIOUS CLINICAL TRIALS 
22 
2.2 STUDY RATIONALE ........................................................................................................................... 23 
2.3 BENEFIT/RISK ASSESSMENT ............................................................................................................ 24 
2.3.1 
RISK ASSESSMENT 
24 
2.3.2 
BENEFIT ASSESSMENT 
24 
2.3.3 
OVERALL BENEFIT: RISK CONCLUSION 
25 
3 TRIAL OBJECTIVES ............................................................................................................ 26 
3.1 OBJECTIVES ...................................................................................................................................... 26 
3.1.1 
PRIMARY OBJECTIVE 
27 
3.1.2 
SECONDARY OBJECTIVES 
27 
3.1.3 
TERTIARY OBJECTIVES 
27 
3.1.4 
SAFETY OBJECTIVES 
27 
3.1.5 
1-YEAR FOLLOW UP ANALYTIC SUB-TRIAL OBJECTIVES
28 
3.2 OUTCOMES ........................................................................................................................................ 28 
3.2.1 
PRIMARY EFFICACY OUTCOME 
28 
3.2.2 
SECONDARY EFFICACY OUTCOMES 
28 
3.2.3 
TERTIARY OUTCOMES 
28 
3.2.4 
1-YEAR FOLLOW UP ANALYTIC SUB-TRIAL OUTCOMES
29 
3.2.5 
SAFETY OUTCOMES 
29 
4 TRIAL DESIGN ...................................................................................................................... 30 
4.1 OVERALL DESIGN ............................................................................................................................. 30 
4.2 SCIENTIFIC RATIONALE FOR STUDY DESIGN .................................................................................. 30 
4.3 JUSTIFICATION FOR THE TARGET STUDY POPULATION ................................................................. 32 
4.4 JUSTIFICATION FOR DOSE ................................................................................................................ 33 
4.5 END OF STUDY DEFINITION.............................................................................................................. 33 
5 STUDY POPULATION .......................................................................................................... 34 
5.1 INCLUSION CRITERIA ....................................................................................................................... 34 
5.2 EXCLUSION CRITERIA ...................................................................................................................... 34 
5.3 LIFESTYLE CONSIDERATIONS .......................................................................................................... 35 
5.4 SCREEN FAILURES ............................................................................................................................ 35 
5.5 STUDY ENROLMENT PROCESS ......................................................................................................... 35 
5.5.1 
IMAGING 
36 


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5.5.2 
CONSENT PROCESS 
37 
5.5.3 
PHYSICAL EXAMINATIONS 
37 
6 STUDY INTERVENTIONS AND CONCOMITANT THERAPY .................................... 38 
6.1 STUDY INTERVENTION ADMINISTRATION ....................................................................................... 38 
6.2 PREPARATION/ HANDLING/ STORAGE/ ACCOUNTABILITY ............................................................. 38 
6.2.1 
STORAGE AND ACCOUNTABILITY 
39 
6.2.2 
DISPOSITION OF STUDY DRUG SUPPLIES 
39 
6.3 MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING ................................................ 40 
6.3.1 
PROCEDURE FOR BREAKING THE RANDOMIZATION CODE 
40 
6.4 STUDY INTERVENTION COMPLIANCE .............................................................................................. 41 
6.5 DOSE MODIFICATION ....................................................................................................................... 41 
6.6 CONTINUED ACCESS TO STUDY INTERVENTION AFTER THE END OF THE STUDY ......................... 41 
6.7 TREATMENT OF OVERDOSE ............................................................................................................. 41 
6.8 CONCOMITANT THERAPY ................................................................................................................ 42 
6.8.1 
RESCUE MEDICINE/TREATMENT 
42 
6.9 ENDOVASCULAR INTERVENTION AND STROKE CARE .................................................................... 43 
7 DISCONTINUATION OF STUDY INTERVENTION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL ................................................................................... 44 
7.1 DISCONTINUATION OF STUDY INTERVENTION ................................................................................ 44 
7.2 PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE TRIAL ............................................. 44 
7.3 LOST TO FOLLOW UP ........................................................................................................................ 44 
8 STUDY ASSESSMENTS AND PROCEDURES ................................................................. 46 
8.1 EFFICACY ASSESSMENTS.................................................................................................................. 46 
8.1.1 
THE MODIFIED RANKIN SCALE 
46 
8.1.2 
MORTALITY RATE 
46 
8.1.3 
WORSENING OF STROKE 
46 
8.1.4 
VOLUME OF STROKES 
46 
8.1.5 
THE NATIONAL INSTITUTES OF HEALTH STROKE SCALE 
47 
8.1.6 
BARTHEL INDEX 
47 
8.1.7 
EQ-5D-5L 
47 
8.2 SAFETY ASSESSMENTS .............................................................................................................. 47 
8.2.1 
VITAL SIGNS 
47 
8.2.2 
CLINICAL SAFETY LABORATORY ASSESSMENTS 
47 
8.2.3 
PREGNANCY TESTING 
48 
8.3 ADVERSE EVENTS (AES), SERIOUS ADVERSE EVENTS (SAES), AND OTHER SAFETY REPORTING
48 
8.3.1 
TIME PERIOD AND FREQUENCY FOR COLLECTING AE AND SAE INFORMATION 
48 
8.3.2 
METHOD OF DETECTING AES AND SAES 
48 
8.3.3 
FOLLOW-UP OF AES AND SAES 
49 
8.3.4 
REGULATORY REPORTING REQUIREMENTS FOR SAES 
49 
8.3.5 
PREGNANCY 
50 
8.4 PHARMACOKINETICS........................................................................................................................ 50 
9 STATISTICS ........................................................................................................................... 52 
9.1 SAMPLE SIZE DETERMINATION ....................................................................................................... 52 
9.2 ANALYSIS SETS ................................................................................................................................. 52 


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9.3 STATISTICAL ANALYSIS ................................................................................................................... 53 
9.3.1 
GENERAL CONSIDERATIONS 
53 
9.3.2 
EFFICACY ANALYSIS 
55 
9.3.3 
ANALYSES OF SAFETY 
59 
9.3.4 
PHARMACOKINETICS 
59 
9.4 INTERIM ANALYSIS ........................................................................................................................... 60 
10 SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS ... 61 
10.1 APPENDIX 1: REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS .................. 61 
10.1.1 REGULATORY AND ETHICAL CONSIDERATIONS 
61 
10.1.2 FINANCIAL DISCLOSURE 
61 
10.1.3 INFORMED CONSENT PROCESS 
62 
10.1.4 DATA PROTECTION 
62 
10.1.5 COMMITTEES STRUCTURE 
63 
10.1.6 DISSEMINATION OF CLINICAL STUDY DATA 
63 
10.1.7 DATA QUALITY ASSURANCE 
63 
10.1.8 SOURCE DOCUMENTS 
64 
10.1.9 STUDY AND SITE START AND CLOSURE 
65 
10.1.10 PUBLICATION POLICY 
66 
10.1.11 AUDITS AND INSPECTIONS 
67 
10.2 APPENDIX 2: CLINICAL LABORATORY TESTS AND IMAGING ....................................................... 68 
10.2.1 CLINICAL LABORATORY TESTS 
68 
10.2.2 IMAGING 
68 
10.3 APPENDIX 3: ADVERSE EVENTS: DEFINITIONS AND PROCEDURES FOR RECORDING, 
EVALUATING, FOLLOW-UP, AND REPORTING .......................................................................................... 69 
10.3.1 DEFINITION OF AE 
69 
10.3.2 DEFINITION OF SAE 
70 
10.3.3 RECORDING AND FOLLOW-UP OF AE AND/OR SAE 
71 
10.3.4 REPORTING OF SAES 
73 
10.4 APPENDIX 4: COLLECTION OF PREGNANCY INFORMATION ......................................................... 74 
10.5 APPENDIX 5: ABBREVIATIONS........................................................................................................ 75 
10.6 APPENDIX 6: COUNTRY-SPECIFIC REQUIREMENTS ...................................................................... 77 
10.6.1 ADDITION TO CONSENT PROCESS- SECTION 5.5.2 
77 
10.6.2 ADDITION TO REMOTE SOURCE DOCUMENT VERIFICATION - SECTION 10.1.7 
77 
11 REFERENCES ...................................................................................................................... 78 
12 INVESTIGATOR’S AGREEMENT ................................................................................... 81 
13 ADDENDUM ......................................................................................................................... 82 
13.1 COVID-19 CONSIDERATIONS ........................................................................................................ 82 
13.2 ASSESSMENT QUESTIONNAIRES ..................................................................................................... 84 


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Tables and Figures 
Figure 1: Inhibition of NO Production by Nerinetide (NA-1) via Perturbation of NMDA Receptor 
PSD-95 Interactions ........................................................................................................................ 21 
Table 1-1: Schedule of Activities- Main Trial ................................................................................ 16 
Table 1-2: Schedule of Activities: 1-Year Follow Up Telemedicine or Telephone Contact.......... 17 
Table 3-1: Objectives and Endpoints .............................................................................................. 26 
Table 6-1: Study Interventions........................................................................................................ 38 
Table 9-1: Statistical Analysis Methods ......................................................................................... 55 
Table 10-1: Protocol-Required Safety Laboratory Assessments .................................................... 68 


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1 
PROTOCOL SUMMARY 
1.1 
Synopsis 
Title 
A Multicentre, Randomized, Double-blinded, Placebo-controlled, Parallel 
Group, Single-dose Design to Determine the Efficacy and Safety of 
Nerinetide in Participants with Acute Ischemic Stroke Undergoing 
Endovascular Thrombectomy Excluding Thrombolysis 
Trial Code 
ESCAPE-NEXT (NA-1-009) 
Trial Design 
This study is a Phase 3, randomized, multicentre, blinded, placebo-
controlled, parallel group, single-dose design with a single interim 
analysis for safety and efficacy. Because AIS is a medical emergency, the 
trial is designed to enable the administration of standard-of-care 
treatments without delay in order to save the life of the person concerned, 
restore good health or alleviate suffering.  
At total of up to 850 male and female participants aged 18 years and older 
harboring an acute ischemic stroke who are selected for endovascular 
revascularization without intravenous or intra-arterial thrombolytic 
therapy will be given a single, 2.6 mg/kg (up to a maximum dose of 270 
mg) intravenous dose of nerinetide or placebo. Randomization will be 
stratified by time from stroke onset to randomization ≤4.5 hours (yes/no) 
and done with stochastic minimization to balance baseline factors within 
strata. Outcomes of the main trial will be evaluated throughout a 90 day 
observation period. 
Participants will be contacted by telemedicine or telephone at 1-Year by 
individuals blinded to the outcome of the main trial.   
Two database locks and corresponding reports are planned for this trial.  
The first report will be based on the completion of Day 90 visits for the 
main trial.  The second report will be following the completion of the 1-
Year follow up for the analytic sub-trial. 
Trial Objectives 
for Main Trial 
The primary objective is to determine the efficacy of the neuroprotectant, 
nerinetide in: 
•
Reducing global disability in participants with acute ischemic
stroke (AIS)
The secondary objectives are to determine the efficacy of nerinetide in: 
1)
Reducing mortality rate
2)
Reducing worsening of stroke*
3)
Reducing functional dependence
4)
Improving neurological outcome
* Worsening of stroke is defined as (A) progression, or hemorrhagic


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transformation of the index stroke, as documented by medical imaging 
that is (a) life-threatening requiring intervention and/or (b) results in 
increased disability as gauged by a ≥4 point increase from lowest NIHSS 
during hospitalization or (B) results in death from the index stroke. 
The tertiary objectives are to determine the efficacy of nerinetide in: 
•
Decreasing infarct volume
•
Improving activities of daily living
•
Reducing dependency or death
•
Improving excellent functional outcome
•
Improving health related quality of life
The safety objectives are to determine the safety in participants with acute 
ischemic strokes of a single 2.6 mg/kg dose (up to a maximum dose of 
270 mg) of intravenous nerinetide, based on serious adverse events 
(SAEs) and 90-day mortality. 
Efficacy 
Outcomes for 
Main Trial 
The primary outcome is: 
•
The proportion of participants with independent functioning on the
modified Rankin Scale (mRS), as defined by a score of 0-2, at Day
90.
The secondary outcomes include: 
1) Mortality rate, as defined by event rate (%) for mortality over the
90-day study period.
2) Proportion of participants exhibiting a worsening of their index
stroke. Worsening of stroke is defined as (A) progression, or
hemorrhagic transformation of the index stroke, as documented by
medical imaging that is (a) life-threatening requiring intervention
and/or (b) results in increased disability as gauged by a ≥4 point
increase from lowest NIHSS during hospitalization or (B) results in
death from the index stroke.
3) A shift of one or more categories to reduced functional dependence
analyzed across the whole distribution of outcomes on the mRS at
Day 90 post randomization.
4) Proportion of participants with good neurological outcome, as
defined by a score of 0-2 on the NIHSS at Day 90 post
randomization.
Tertiary outcomes include: 
•
Volume of stroke as measured by MRI or CT brain imaging (MRI
preferred).


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•
Proportion of participants with functional independence in
activities of daily living, as defined by a score of ≥ 95 on the Barthel
Index (BI) at Day 90 post randomization.
•
Proportion of participants with reduced moderate or severe
disability or death, as defined by a score of 4-6 on the mRS at Day
90 post randomization.
•
Proportion of participants with excellent functional outcome, as
defined by a score of 0-1 on the mRS at Day 90 post randomization.
•
Health-related quality of life, as measured by the EQ-5D-5L at Day
90.
Trial Objectives 
for Analytic 
Sub-Trial at 1-
Year Follow-up 
There will be an analytic 1-Year follow-up sub-trial investigating the 
long-term effects of nerinetide treatment.  
The primary objective is to determine the efficacy of the neuroprotectant, 
nerinetide at 1-Year post randomization in:  
•
Reducing global disability in participants with acute ischemic
stroke (AIS).
The secondary objectives are to determine the efficacy of nerinetide in: 
•
Reducing mortality rate
•
Improving activities of daily living
•
Improving health related quality of life
Efficacy 
Outcomes for 1-
Year Follow-up  
The primary outcome of the 1-Year follow-up is: 
•
The proportion of participants with independent functioning on the
modified Rankin Scale (mRS), as defined by a score of 0-2 at 1-
Year post randomization.
The secondary outcomes include: 
•
A reduction in mortality rate, as defined by event rate (%) for
mortality over the 1-Year study follow-up period.
•
The proportion of participants with independent function on
activities of daily living defined on the Barthel Index (BI) with a
score of ≥ 95 at 1-Year post randomization.
•
Health-related quality of life, as measured by the EQ-5D-5L at 1-
Year post randomization.
Safety Outcomes 
for Main Trial 
Safety outcomes include: 
•
Serious adverse events (SAEs) to Day 90.
•
90-day mortality.


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Additional Safety outcomes include: 
•
Adverse events (AEs) to Day 30.
•
Discontinuations due to AEs.
•
Baseline and Day 2 post-dose study drug laboratory tests.
•
Baseline and post-dose (to Day 2) study drug vital signs.
Number of 
Participants 
 Up to 850 male and female participants harboring AIS and who are 
selected for endovascular revascularization without intravenous or intra-
arterial thrombolytic therapy will be enrolled. 
Inclusion/ 
Exclusion 
Criteria 
Inclusion Criteria 
1) Acute ischemic stroke (AIS) selected for emergency endovascular
treatment.
2) Age 18 years or greater.
3) Onset (last-known-well) time to randomization time within 12 hours.
4) Disabling stroke defined as a baseline National Institutes of Health
Stroke Score (NIHSS)
a.
NIHSS > 5 for internal carotid artery (ICA) and M1-middle
cerebral artery (MCA) occlusion or
b. NIHSS > 10 for M2-MCA occlusion.
5) Confirmed symptomatic intracranial occlusion at one or more of the
following locations: Intracranial carotid I/T/L, M1 or M2 segment
MCA.  Tandem extracranial carotid and intracranial occlusions are
permitted.
6) Pre-stroke (24 hours prior to stroke onset) independent functional
status in activities of daily living with modified Barthel Index (BI) ≥
95. Patient must be living without requiring nursing care.
7) Qualifying imaging performed less than 2 hours prior to
randomization.
8) Consent process completed as per national laws and regulation and the
applicable ethics committee requirements.
Exclusion Criteria 
1) Treated with a tissue plasminogen activator (e.g., alteplase or
tenecteplase) within 24 hours before randomization.
2) Determination by the treating physician, based on current treatment
guidelines and medical evidence, that treatment with a plasminogen
activator is indicated.
3) Large core of established infarction defined as ASPECTS 0-4.


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4) Absent or poor collateral circulation on qualifying imaging (e.g.,
Collateral score of 0 or 1).
5) Any intracranial hemorrhage on the qualifying imaging.
6) Planned use of an endovascular device not having approval or
clearance by the relevant regulatory authority.
7) Endovascular thrombectomy procedure is completed as defined by the
presence of TICI 2c/3 reperfusion or completion of groin / arterial
closure.
8) Clinical history, past imaging or clinical judgment suggesting that the
intracranial occlusion is chronic or there is suspected intracranial
dissection such that there is a predicted lack of success with
endovascular intervention.
9) Estimated or known weight > 120 kg (264 lbs).
10) Pregnancy/Lactation; female, with positive urine or serum beta human
chorionic gonadotropin (β-hCG) test, or breastfeeding.
11) Known prior receipt of nerinetide for any reason, including prior
enrolment in this ESCAPE-NEXT trial.
12) Severe known renal impairment defined as requiring renal
replacement therapy (hemo- or peritoneal dialysis).
13) Severe or fatal comorbid illness that will prevent improvement or
follow up.
14) Inability to complete follow-up treatment to Day 90.
15) Participation in another clinical trial investigating a drug, medical
device, or a medical procedure in the 30 days preceding trial
inclusion.
Countries 
Global, multicentre trial 
Treatment 
Nerinetide 2.6 mg/kg (up to a maximum dose of 270 mg or matching 
placebo volume) will be administered as a single 10±1minute intravenous 
infusion using an infusion pump starting after randomization.   
Consent 
Initial Informed Consent 
Participants or their legally authorized representative will be required to 
sign a statement of informed consent that meets the requirements of 
applicable national laws and regulation and the ethics committee. 
See Appendix 10.6.1 for additional country specific details. 
Regained Capacity Consent  
If the original consent process involved anyone other than the participant, 
and if required by local standards, consent will be sought for the 


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remaining procedures from the participant once they are deemed to have 
regained capacity.  
Note: Electronic consent tools may be used for initial and regained 
capacity consent, as permitted under national laws and regulations and the 
applicable Independent Review Boards/Ethics Committee.  
Randomization 
Method 
Treatment will be assigned using 1:1 randomization (nerinetide:placebo) 
with a stratification based on time from stroke onset to randomization of 
less than or equal to 4.5 hours (yes/no) and a randomized minimization 
algorithm to minimize the contribution of imbalances in baseline factors 
(age, sex, baseline NIHSS score, baseline ASPECT score, occlusion 
location, time from qualifying imaging to randomization, and site).  
Duration of 
Treatment 
Participants will receive a single 10-minute infusion of study drug. This 
trial consists of one 90-day study period for each participant.  Participants 
will be hospitalized for care after their acute stroke according to the 
current standard of care. At Day 30 and Day 90 it is preferred that 
participants will return to clinic. If an in-clinic visit is not possible, the 
participant can be contacted by telemedicine (preferred) or by telephone 
(last option). 
For the purpose of the analytic 1-Year sub-trial, participants will be 
contacted by telemedicine or telephone. 
The end of the study is defined as the date of the last contact of the last 
participant in the trial at the 1-Year follow up.   
Laboratory 
Tests 
If the participant is female and is of childbearing potential, a pregnancy 
test (urine or serum point-of-care pregnancy test) must be completed and 
a negative test result obtained prior to inclusion in the trial. 
In order to support the assessment of safety, baseline (pre-dose) and post-
dose (Day 2) hematology, electrolytes and chemistry laboratory results 
will be reported and analysed.  
Assessment of 
Efficacy and 
Power 
The primary estimand will be the adjusted unconditional population 
difference in the mRS response (i.e., mRS score of 0-2) proportions 
between treatment conditions (nerinetide vs. placebo) in the target patient 
population at Day 90. Deaths occurring over the Day 90 period will be 
considered as non-responses.  
Assuming a 50% overall responder rate for the placebo group population 
(as observed in the ESCAPE-NA1 trial), there will be approximately 
91.3%power to detect an 11.4% absolute effect difference between 
response rate (proportion of responders, with Day 90 mRS in the range 0 
to 2 with nerinetide and placebo, at alpha level 0.25 one-sided (0.05 2-
sided), using the planned sample size of 850 evaluable subjects, 
randomized 1:1, per group [EaST v6.5, 2022]. 


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The interim analysis is planned to take place at 60% information (primary 
endpoint), i.e., when approximately 510 of the target 850 patients have 
reached their primary endpoint assessment. The cumulative alpha spent at 
the interim analysis is 0.004 and final analysis 0.025, one-sided (0.05 2-
sided); the stopping boundaries on the Z scale are 2.668 (interim) and 
1.981 (final) and on the p-value scale 0.004 (interim) and 0.021 (final), all 
on the assumption that the interim is conducted at 60% information.  
Statistical 
Assumptions 
The primary and secondary efficacy endpoint analyses will be conducted 
on the intent-to-treat (ITT) population, defined as all randomized 
participants, regardless of treatment actually received.  The primary 
analysis will be repeated on the Per Protocol (PP) population.  An ITT 
analysis will also be conducted for the secondary endpoints, with 
participant grouped according to the randomized (intended) treatment. 
The pivotal primary analysis for the primary estimand model will be a 
logistic regression model with fixed effects including the treatment group, 
the stratification covariate of time from stroke onset to randomization ≤ 
4.5 hours (yes/no) and the randomized minimization factors (age, sex, 
baseline NIHSS score, occlusion location, time from qualifying imaging 
to randomization, baseline ASPECT score, sex, and pooled site), and an 
interaction term of treatment by time from stroke onset to randomization. 
If the interaction term is not significant at the level of 0.05 it will be 
removed from the model.  
The analysis for the secondary estimands with binary endpoints will be 
based on the ITT population following the same methods as the primary 
(logistic regression based, with the odds ratios along with the 95% CI 
reported in addition to the primary Ge et al, 2011 method results) and 
secondary (two sample proportion test) analyses of the primary estimand. 
Mortality analysis will be additionally supported using time-to-death 
survival function analysis, both unadjusted shown using Kaplan-Meier 
analysis and adjusted via Cox proportional hazards regression. 
For the secondary estimand of the “mRS shift analysis”, the first step in 
the analysis will be an analysis with mRS score 5 and 6 combined, using a 
proportional odds model to derive the common odds of improvement 
(“shift”) along the mRS scale. It will be adjusted for the same covariates 
as the primary analysis. The mRS shift analysis will only be conducted as 
part of the fixed sequence testing sequence provided that the proportional 
odds assumption is found to be valid on testing. If it is found to be 
invalid, the remaining secondary endpoints will be analyzed in the fixed 
testing sequence specified without the mRS shift analysis; i.e. it will be 
removed from the fixed sequence testing sequence. Adjustment will 
include the same variables as the specified in the adjusted logistic 
regression model for the primary estimand.  


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The secondary outcome of NIHSS scores at Day 90 will be dichotomized 
into 0-2 (indicating a good neurological outcome) versus >2 (indicating 
otherwise). The proportion of participant achieving a good neurological 
outcome at Day 90 in nerinetide versus placebo control participants will 
be compared using the same approach as the primary analysis, both 
adjusted and unadjusted. 
The total lesion volume of new strokes on MRI or CT brain imaging in 
the nerinetide versus placebo control participants will be assessed using 
an unadjusted two-tailed Student’s t-test and supported bya linear 
regression that includes the stratification and minimization variables. 
Secondary outcomes will be assessed in a pre-defined hierarchical order. 
The tertiary outcomes comprising proportions of responders will be 
analyzed similarly to the primary outcome or will be assessed 
descriptively.  
Three separate efficacy analysis timepoints are planned for this trial. The 
first analysis will be at the interim analysis planned at 60% information 
on the primary endpoint. The second analysis timepoint will be based on 
the completion of Day 90 visits for the main trial. The third analysis will 
be following the completion of the 1-Year follow up. 
For the safety analysis, the frequency of SAEs, SAEs resulting in death, 
AEs and discontinuations due to AEs will be summarized.   
Independent 
Data Monitoring 
Committee 
An Independent Data Monitoring Committee (IDMC) will monitor patient 
safety and scientific integrity during the trial.  
The interim analysis for efficacy during the trial will also be assessed by 
the IDMC. The interim efficacy analysis will be performed after 
approximately 510 participants have complete the Day 90 follow-up, at 
60% information on the primary endpoint.  
Bioanalytical 
Sampling 
Plasma samples from up to 100 participants in North America (Canada 
and the US) will be collected for potential pharmacokinetic assessment. 


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Table 1-1: Schedule of Activities- Main Trial 
Visit/Contact 
V1 
V2 
V3 
V4 
V5 
V6 
Day 
Day 1 
Baseline 
Day 1 
Post-EVT 
Day 2/3 
Day 61 or 
discharge 
Day 302 
Day 902 
Window 
(~2 h) 
(18-56 h) 
(±5 d) 
(-21 to +7d) 
Informed consent 
X 
Regained capacity informed consent3 
X 
X 
X 
X 
History and physical examination 
X 
Weight4 
X 
Vital Signs (BP, HR, Temperature) 5 
X 
X 
X 
Randomization/  
Study drug administration 
X 
Mortality 
X 
X 
X 
X 
X 
NIHSS 
X 
X 
X 
X 
X 
X 
mRS6 
X 
X 
X 
X 
Barthel Index 
X 
X 
X 
EQ-5D-5L 
X 
Qualifying Imaging 
X 
Endovascular Procedure 
X 
MRI/NCCT head7 
X 
Laboratory Assessments 
X8 
X 
Pregnancy test9 
X 
Pharmacokinetic samples10 
X 
AE 
Collected to Day 30 
SAE 
Collected to Day 90 
Prior medications 
X 
Concomitant medications 
Collected to Day 6 or discharge 
1.
Visit will occur at Day 6 or hospital discharge if prior to Day 6.
2.
At Day 30 and Day 90 it is preferred that participants will return to clinic.  If a in clinic visit is not possible the participant can
be contacted by telemedicine (preferred) or by telephone (last option).
3.
If the original process involved anyone other than the participant (and if required), site staff will make ongoing efforts until: (1)
regained capacity consent is obtained from participant, (2) death, or (3) completion of the Day 90 assessment.
4.
At baseline estimated or actual weight will be collected. If an estimated weight was collected at baseline, actual weight should
be collected as soon as feasible and prior to discharge. 
5.
Vital signs (BP, HR only) will be recorded immediately before and after completion of the study drug infusion, temperature will 
be collected at baseline only if standard of care.
6.
Historical (pre-stroke) mRS score can be collected at any time.
7.
MRI head may be supplanted by an NCCT head if MR is unavailable or contraindicated.
8.
Blood should be drawn at baseline, but results are not required prior to randomization. Results from primary hospital (within 8
hours) are accepted.
9.
If the participant is female and is of childbearing potential a pregnancy test (urine or serum point-of-care pregnancy test) must
be completed and the result must be negative; this is the only mandatory laboratory test prior to randomization.
10. PK samples will be collected from up to 100 participants: pre-dose and at 10, 20, 30 and 60 min after the start of study drug
administration.
d = days; h = hours 


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Table 1-2: Schedule of Activities: 1-Year Follow Up Telemedicine or Telephone Contact 
Contact 
V7 
1-Year Follow up
Day 
Day 365 
Window 
(±30 d) 
Mortality 
X 
EQ-5D-5L 
X 
mRS 
X 
Barthel Index 
X 


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1.2 
Coordinating Centre and Sponsor 
Coordinating Centre 
Overall Coordinating 
Investigator: 
Co-Coordinating 
Investigator 
Sponsor: 
Sponsor Medical Oversight 
Imaging Adjudication 
Pharmacokinetic Analysis 
Personal Protected Data


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2 
INTRODUCTION 
2.1 
Background 
Stroke is a leading cause of mortality and neurological disability worldwide1-3. When blood flow 
to the brain is interrupted during a stroke, some brain cells die immediately, while others remain 
at risk for death. These damaged cells make up the ischemic penumbra and can linger in a 
compromised state for periods varying from minutes to several hours4-6.   Given that there is a 
critical time, a “therapeutic window”, which may vary from minutes to a few hours in which 
cerebral ischemia can be reversed or mitigated, stroke should be treated as a medical emergency 
and treatment should commence without delay in order to save the life of the person concerned, 
restore good health and alleviate suffering.  
Brain tissue is rapidly and irretrievably lost as stroke progresses8 and  early intervention is critical 
to improve stroke  outcome. Alteplase, recombinant tissue plasminogen activator, is the only 
approved pharmacological treatment for acute ischemic stroke (AIS) and must be administered 
within 3-4.5 hours of symptom onset, and only in those patients for which the possibility of 
hemorrhagic stroke was excluded. According to the 2017 claims data only 10% of all ischemic 
strokes in the USA are treated with alteplase.   
Endovascular thrombectomy (EVT) is being used with or without alteplase to retrieve blood clots 
in AIS caused by large vessel occlusion (LVO)9. Even with EVT, only about 10% patients return 
to normal after their AIS9, and only approximately half reach functional independence10.  
Therefore, although reperfusion therapies improve stroke prognosis, there remains a significant 
unmet medical need. Such a need would be fulfilled by a neuroprotective therapy – one that 
enhances the brain’s resilience to ischemia. However, at present, no approved neuroprotective 
pharmacotherapy exists. 
Nerinetide (NA-1) is a first in class neuroprotectant that is designed to address the major unmet 
medical need for treatments that reduce the functional disability produced by acute stroke. It 
reduces the vulnerability of ischemic brain tissue to hypoperfusion by targeting neurotoxic 
pathways that lead to ischemic neuronal death. Nerinetide is intended, alone or in combination 
with available therapies, to treat acute stroke, a serious and life-threatening disease.    
For this reason, nerinetide is being developed as a drug for use in emergency situations aimed at 
reducing global disability in patients with acute ischemic stroke.  Nerinetide may provide 
significant benefit for the treatment of acute cerebral ischemia if administered to stroke patients 
who present to medical attention before infarction is complete. The rapid progression of 
irreversible brain injury in most acute strokes implies a short window of clinical efficacy of any 
treatment, including nerinetide.  The ability to identify patients with salvageable brain using the 
criteria used in the ESCAPE trial11 and the ESCAPE-NA1 trial12 provides an opportunity to target 
patients who may have the greatest benefit from neuroprotection, and to enhance further the 
impact of reperfusion therapies. The preclinical and clinical data support this notion. 
A detailed description of the chemistry, pharmacology, efficacy, and safety of nerinetide is 
provided in the Investigator’s Brochure. 
 


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2.1.1 Nerinetide (NA-1): A Post-synaptic Density 95 Inhibitor 
Nerinetide (NA-1) is a first in class neuroprotectant that is designed to address the major unmet 
medical need for treatments that reduce the functional disability produced by acute stroke. It 
reduces the vulnerability of ischemic brain tissue to hypoperfusion by targeting neurotoxic 
pathways that lead to ischemic neuronal death. Nerinetide is intended, alone or in combination 
with available therapies, to treat acute stroke, a serious and life-threatening disease.  
Nerinetide (NA-1) is a novel synthetic peptide composed of two parts: a 9 amino acid active 
substance that binds to post-synaptic density protein 95 (PSD-95), and an 11 amino acid sequence 
that allows delivery across the blood brain barrier and cell membranes into the neuronal target 
cells. Nerinetide is designed to target post-synaptic density protein-95 (PSD-95), which binds both 
the N-methyl-D-aspartate receptors (NMDARs) and neuronal nitric oxide synthases (nNOS) at 
excitatory synapses to form the NMDAR/PSD-95/nNOS complex that efficiently translates 
NMDAR overactivation to NO production during cerebral ischemia. Nerinetide inhibits the 
protein-protein interaction between PSD-95 and the GluN2B subunits of NMDARs, as well as the 
interactions between nNOS and PSD-9513. This inhibition uncouples nNOS from NMDAR 
activity in order to prevent or limit the onset of neuronal excitotoxicity that is associated with AIS 
and other disorders in which glutamatergic mechanisms play a pathophysiological role. Nerinetide 
has no effect on other known NMDAR functions, but results in decreases in downstream 
neurotoxic signaling (i.e., NO production). Figure 1 summarizes the mechanism of inhibition of 
nitric oxide (NO) by nerinetide (NA-1).  
Based on pharmacokinetic studies, the plasma half-life of nerinetide at doses in the therapeutic 
range is in the 6-15 minute range. 


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Figure 1: Inhibition of NO Production by Nerinetide (NA-1) via Perturbation of NMDA 
Receptor PSD-95 Interactions 
2.1.2 Impact of Alteplase on Nerinetide 
Nerinetide is intended to be used as a standard of care stroke therapy. The only currently approved 
pharmacological agent for treating AIS is alteplase, a thrombolytic agent. Nerinetide has amino-
acid sequences known to be cleaved by plasmin, a serine protease generated from clot-bound 
plasminogen by tissue-plasminogen activators such as alteplase14. Nerinetide does not have any 
intrinsic fibrinolytic activity and does not affect the activity of thrombolytics such as alteplase or 
tenecteplase15 but the converse is different. Plasmin, a serine protease, is activated by 
thrombolytic drugs to dissolve fibrin blood clots and, although plasmin itself has a very short half 
life in human blood, its effects persist for several hours16. Plasmin has a similar substrate 
specificity to trypsin17, which is predicted to cleave nerinetide after residues 3, 4, 5, 6, 7, 9, 11 and 
12 from the N-terminus (https://web.expasy.org/peptide_cutter/). Similar cleavage products were 
observed after incubating nerinetide with plasmin in vitro18. Incubating nerinetide with alteplase 
in rat or human plasma reduced the nerinetide content in both. Concurrent administration of 
nerinetide and alteplase to rats caused a significant lowering of nerinetide levels18.  
2.1.3  
Thrombectomy As a Stroke Treatment 
Medical devices may be used with or without alteplase to retrieve blood clots in large cerebral 
arteries that cause severe brain ischemia (“endovascular thrombectomy”)9. The evidence that 
endovascular therapy (EVT) is effective in improving neurological outcome is strongest in 
patients who have the combination of an LVO as well as direct or indirect imaging evidence of 
salvageable brain (an ischemic penumbra) at the time of treatment initiation.  Current generation 
devices are intended for patients whose AIS is caused by a LVO, and produce higher rates of 
reperfusion than alteplase in such appropriately selected patients.  However, even with EVT, only 
about 10% patients return to normal as defined by modified Rankin Score (mRS) = 0 after their 


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AIS9, and only approximately half become functionally independent10.  In other words, about half 
of patients who receive EVT still remain functionally dependent or die from their stroke. 
Moreover, although still the participant of intense study in ongoing randomized trials, clinical data 
available to date suggest there is no significant difference in outcomes between patients who were 
treated with EVT only as compared with those who received combined thrombolysis with 
alteplase and EVT19-21.  
Although reperfusion therapies such as alteplase and/or EVT improve stroke prognosis, a 
significant need remains to reduce the overall number of AIS patients who have poor outcomes. 
As such, stroke remains a serious condition, with an unmet medical need. 
2.1.4 Treatment of Stroke with Nerinetide in Non-Human Primates 
To test whether nerinetide is beneficial when administered later in the setting of a prolonged 
temporary middle cerebral artery occlusion (tMCAO), 24 cynomolgus macaques received a 10-
minute infusion of nerinetide or placebo three hours after the onset of a 3.5 hour tMCAO.  There 
were no mortalities.  Final imaging and neurological assessments were conducted at 14 days.  
Nerinetide treated animals exhibited significant reductions in infarct volumes as compared with 
placebo as evaluated on MRI (T2-weighted MRI:  at 48 hours: p=0.006; DWI MRI at 48 hours: 
p=0.004; T2-weighted MRI at 14 Days: p=0.003).   
Animals treated with nerinetide exhibited improved non-human primate stroke score (NHPSS) 
scores throughout the 14-day observation period days [p=0.004, two-way repeated measures 
analysis of variance] and trended to better performance in the six-well and the valley staircase 
tasks22. There were no statistically significant differences in any of the physiological parameters 
(including MAP) at any of the measured time points for the nerinetide versus placebo treated 
animals.   
More detailed information on these and other non-human primate studies are provided in the 
Investigator’s Brochure.   
2.1.5 Previous Clinical Trials 
Three clinical trials with nerinetide have been completed to date.  
The results of a Phase 1 trial conducted in healthy volunteers indicate that nerinetide is well 
tolerated when administered in doses ranging between 0.02 and 2.60 mg/kg and a dose of 2.6 
mg/kg was selected for further clinical trials.  No serious adverse events (SAEs) or 
discontinuations due to adverse events were reported in the trial.   
In the Phase 2 ENACT clinical trial using a dose of 2.60 mg/kg in patients undergoing 
endovascular repair of brain aneurysms, both unruptured and ruptured, the data suggest a 
treatment effect of nerinetide on the procedurally – induced strokes.  The treatment effect was 
most evident when evaluating lesion counts using DWI or FLAIR imaging, and also in 
exploratory analyses when evaluating lesion volume in the mITT population. The treatment effect 
was most pronounced in participants who suffered from a ruptured brain aneurysm, in whom 
infarct numbers and infarct volumes were reduced.  Exploratory analyses suggested that stroke 
volumes were also reduced when analyses accounted for delayed strokes, or for the non-normality 
of the data. There were three deaths during this trial, two in the placebo group and one in the 


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nerinetide group. The SAEs leading to death were all severe and unrelated to study drug. There 
were no other discontinuations due to adverse events. Overall, nerinetide (NA-1) 2.60 mg/kg was 
well-tolerated and no safety concerns were identified in any of the patient groups in the trial. 
The selection of the single IV dose of 2.60 mg/kg is based on the safety and tolerability profile of 
nerinetide observed in the Phase 1 and 2 clinical trials.  
In the ESCAPE-NA1 trial, treatment with single 2.6 mg/kg IV dose of nerinetide did not achieve 
the primary endpoint of the trial in all participants with ischemic stroke due to large vessel 
occlusion and who were selected for EVT, with and without intravenous alteplase. Among 
participants who were not treated with alteplase, a treatment effect was observed. Specifically, 
there was a benefit in the nerinetide group on the proportion of participants achieving an mRS 0-2 
at 90 days (59.4% for nerinetide participants vs. 49.8% for placebo participants) (Odds 
Ratio = 1.657; 95% CI 1.055, 2.603; p = 0.028). There was also a reduction in mortality rate in the 
participants receiving nerinetide with an absolute reduction in mortality rate of 7.5% (relative 
difference of 39.7%; p = 0.041, Fisher’s Exact Test) without an increase in severe disability (i.e., 
mRS 4 or 5). Other measures of function, including the NIHSS and BI trended in the same 
direction, in favor of nerinetide. Lastly, treatment with nerinetide resulted in a significant 
reduction in median infarct volumes in the nerinetide group (p = 0.048). 
The results of the safety analysis from the ESCAPE-NA1 trial indicate that nerinetide was well 
tolerated when given as a single IV dose of 2.6 mg/kg with most adverse events occurring with a 
similar frequency in the drug and placebo groups. The only exception to that was an increase in 
serous hypotension immediately (within 2 hours) following the administration of nerinetide (6 
SAEs in nerinetide vs. 0 in placebo). These cases were reported resolved within 2 days. There 
were no other differences in other important safety outcomes observed.  When nerinetide is 
administered without alteplase there were fewer deaths and a fewer number of neurological 
serious adverse events (including stroke in evolution, ischemic stroke and hemorrhagic 
transformation). When nerinetide is administered with alteplase there were no differences in 
important safety outcomes observed between the nerinetide and placebo groups.  
2.2 
Study Rationale  
The rationale for the ESCAPE-NEXT trial is based on promising results from the recently 
completed ESCAPE-NA1 trial12 and to confirm the findings that nerinetide may improve functional 
independence, reduce mortality, and reduce infarction volumes in participants with AIS who are 
selected for EVT and who are not treated with thrombolytics.  
ESCAPE-NA1 was a randomized, multicentre, blinded, placebo-controlled, parallel group, single-
dose trial conducted at 48 sites in the USA, Canada, Ireland, the UK, Sweden, Germany, Republic 
of Korea, and Australia. While a treatment benefit of nerinetide for the primary outcome in the 
trial population was not observed, a large absolute benefit of treatment with nerinetide over 
placebo was observed in participants not treated with alteplase. In the subgroup of participants 
that did not receive alteplase, the improvement in functional outcome was accompanied by 
reduced mortality and these clinical effects were mirrored by the imaging biomarker of reduced 
infarct volumes in the nerinetide-treated group. The effectiveness of nerinetide on improving 
functional independence, mortality, and infarction volumes in the no-alteplase stratum was not 
seen in the stratum treated with alteplase. This is consistent with the hypothesis that nerinetide 


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was cleaved and inactivated as a result of the administration of alteplase. The data from ESCAPE-
NA1 are also consistent with a significant body of preclinical studies in rodents and primates 
showing that nerinetide reduces infarct burdens and improves functional outcomes in 
experimental animals.  The effectiveness of nerinetide in participants who did not receive prior 
alteplase underlies the rationale for selecting such participants for the present study. This rationale 
is discussed further in Section 4.3. 
There is a compelling need to develop neuroprotectants in order to increase the proportion of 
patients who may benefit from EVT. These agents could improve the outcomes of patients and 
render more patients with AIS into candidates for endovascular or pharmacological recanalization 
treatment. The rapid progression of irreversible brain injury in most acute strokes implies a 
short window of clinical efficacy of any treatment, including nerinetide.  
2.3 
Benefit/Risk Assessment 
More detailed information about the chemistry, pharmacology, efficacy, safety and expected 
benefits and risks of nerinetide is provided in the Investigator’s Brochure.   
2.3.1 Risk Assessment 
Based on the clinical data available for nerinetide to date, the major possible risk for the proposed 
use is: 
• Higher rate of (transient) hypotension due to a transient elevation of blood histamine  
• Effect modification by prior use of alteplase  
2.3.2 Benefit Assessment 
The following is a list of possible benefits to the trial participants in ESCAPE-NEXT: 
• improved functional outcome (mRS 0-2) 
• reduced stroke mortality  
• improved good neurologic outcome (NIHSS 0-2)  
• reduced chance of stroke worsening 
• improved functional independence (BI>95)  
• contribution to the process of developing new therapies in an area of unmet medical need 
Based on the clinical data available for nerinetide to date, treatment with nerinetide may slow the 
progression of ischemic brain damage, providing more time during which endovascular 
thrombectomy may be of benefit to the patient. This is of even greater relevance during the global 
COVID-19 pandemic for the following reasons: 
a) There is a necessity to protect hospital staff, resulting in additional hospital protocols 
involving sanitations and personal protective equipment that minimize the exposure of the 
clinical stroke team to a potentially COVID-19 positive stroke patient (there is no time for 
COVID-19 testing to be completed). 


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b)  There is a necessity to protect the patient, resulting in additional hospital protocols 
involving distancing him/her from hospital staff and sanitizing equipment (e.g., CT 
scanner) used on other patients. 
These necessities slow down emergency stroke care workflows, potentially causing undue delays 
in the emergency stroke care of all AIS patients, not just those who may have been exposed to 
COVID-19. Thus, the possibility that nerinetide, by slowing the progression of ischemic brain 
damage, mitigates such delays may be of direct benefit to treated patients. Further details related 
to COVID-19 considerations are provided in Section 13.1. 
2.3.3 Overall Benefit: Risk Conclusion 
The potential risks identified in association with nerinetide are justified by the anticipated benefits 
that may be afforded to participants with acute ischemic stroke. 
Overall, nerinetide administered as a single intravenous dose was well tolerated at doses up to and 
including 2.6 mg/kg, and no safety concerns have been identified in any of the patient groups in 
the clinical trials. 
 


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3 
TRIAL OBJECTIVES 
3.1 
Objectives 
Table 3-1: Objectives and Endpoints 
Objectives 
Endpoints 
Primary 
 
Reducing global disability in participants 
with acute ischemic stroke (AIS). 
The proportion of participants with independent 
functioning on the modified Rankin Scale 
(mRS), as defined by a score of 0-2 at Day 90. 
Secondary 
 
Reducing mortality rate. 
Proportion of participant mortality over the 90-
day study period. 
Reducing worsening of stroke 
Proportion of participants with a worsening of 
stroke over the 90-day study period. 
Reducing functional dependence. 
A shift of one or more categories to reduced 
functional dependence analyzed across the whole 
distribution of outcomes on the mRS at Day 90. 
Improving neurological outcome. 
Proportion of participants with a score of 0-2 on 
the NIHSS at Day 90. 
Tertiary/Exploratory 
 
Decreasing infarct volume. 
Volume of stroke as measured by MRI or CT 
brain imaging (MRI preferred). 
Improving activities of daily living. 
Proportion of participants with a score of ≥ 95 on 
the Barthel Index (BI) at Day 90. 
Reducing dependency or death. 
Proportion of participants with a score of 4-6 on 
the mRS at Day 90. 
Improving excellent functional outcome.  
Proportion of participants with a score of 0-1 on 
the mRS at Day 90. 
Improving health related quality of life. 
Health-related quality of life, as measured by the 
EQ-5D-5L at Day 90. 
Safety 
 
To determine the safety based on serious 
adverse events (SAEs).  
Proportion of participants with serious adverse 
events to Day 90. 
90-day mortality. 
Proportion of participants alive at 90-day. 
 


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1-Year Follow Up 
Objectives 
Endpoints 
Reducing global disability in participants with 
acute ischemic stroke (AIS). 
Proportion of participants with independent 
functioning on the modified Rankin Score 
(mRS) score of 0-2 at 1-Year. 
Reducing mortality rate. 
Proportion of participant mortality at 1-Year. 
Improving activities of daily living. 
Proportion of participants with a score of ≥ 95 
on the Barthel Index (BI) at 1-Year. 
Improving health related quality of life. 
Health-related quality of life, as measured by 
the EQ-5D-5L at 1-Year. 
3.1.1 Primary Objective 
The primary objective is to determine the efficacy of the neuroprotectant, nerinetide in reducing 
global disability in participants with acute ischemic stroke (AIS). 
3.1.2 Secondary Objectives 
The secondary objectives are to determine the efficacy of nerinetide in: 
1) Reducing mortality rate 
2) Reducing worsening of stroke* 
3) Reducing functional dependence 
4) Improving neurological outcome 
* Worsening of stroke is defined as (A) progression, or hemorrhagic transformation, of the index 
stroke as documented by medical imaging that is (a) life-threatening requiring intervention and/or 
(b) results in increased disability as gauged by a ≥4 point increase from lowest NIHSS during 
hospitalization or (B) results in death from the index stroke.  
3.1.3 Tertiary Objectives 
The tertiary objectives are to determine the efficacy of nerinetide in: 
• 
Decreasing infarct volume 
• 
Improving activities of daily living 
• 
Reducing dependency or death 
• 
Improving excellent functional outcome. Improving health related quality of life 
3.1.4 Safety Objectives 
The safety objectives are to determine the effect of administering a dose of 2.6 mg/kg (up to a 
maximum dose of 270 mg) intravenous infusion of nerinetide to participant with acute stroke on 
SAEs and 90-day mortality. 


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3.1.5 1-Year Follow Up Analytic Sub-Trial Objectives 
There will be a 1-Year follow-up analytic sub-trial to support the outcomes obtained at Day 90.  
The primary objective is to determine the efficacy of the neuroprotectant, nerinetide in:  
• Reducing global disability in participants with acute ischemic stroke (AIS). 
The secondary objectives are to determine the efficacy of nerinetide in: 
• Reducing mortality rate 
• Improving activities of daily living 
• Improving health related quality of life 
3.2 
Outcomes 
3.2.1 Primary Efficacy Outcome 
The primary outcome is the proportion of participants with independent functioning on the 
modified Rankin Scale (mRS), as defined by a score of 0-2 at Day 90 post randomization.  These 
participants are defined to be responders (See Section 9.3.1 for further details). 
3.2.2 Secondary Efficacy Outcomes 
Secondary outcomes include: 
1) A reduction in mortality rate, as defined by event rate (proportion, expressed as a 
percentage) for mortality over the 90-day study period. 
2) Proportion of participants with worsening of stroke over the 90-day study period. 
3) A shift of one or more categories to reduced functional dependence analyzed across the 
whole distribution of outcomes on the mRS at Day 90 post randomization. 
4) Proportion of participants with good neurological outcome, as defined by a score of 0-2 on 
the NIHSS at Day 90 post randomization. 
3.2.3 Tertiary Outcomes 
The following tertiary outcomes will be assessed descriptively: 
• Volume of stroke as measured by MRI or CT brain imaging (MRI preferred).    
• Proportion of participants with functional independence in activities of daily living, as 
defined by a score of ≥ 95 on the Barthel Index (BI) at Day 90 post randomization. 
• Proportion of participants with reduced moderate or severe disability or death, as defined by 
a score of 4-6 on the mRS at Day 90 post randomization.  
• Proportion of participants with excellent functional outcome, as defined by a score of 0-1 
on the mRS at Day 90 post randomization.  
• Health-related quality of life, as measured by the EQ-5D-5L at Day 90. 


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3.2.4 1-Year Follow Up Analytic Sub-Trial Outcomes 
The primary outcome is the proportion of participants with independent functioning on the modified 
Rankin Scale (mRS), as defined by a score of 0-2 at 1-Year. 
The secondary outcomes include: 
• A reduction in mortality rate, as defined by event rate (%) for mortality over the 1-Year 
study period. 
• The proportion of participants with independent function on activities of daily living 
defined on the modified Barthel Index (BI) with a score of ≥ 95 at 1-Year. 
• Health-related quality of life, as measured by the EQ-5D-5L at 1-Year. 
3.2.5 Safety Outcomes  
The safety outcomes are the frequencies of SAEs and 90-day mortality. 
 
 


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4 
TRIAL DESIGN 
4.1 
Overall Design 
This study is a Phase 3, randomized, multicentre, blinded, placebo-controlled, parallel group, 
single-dose design with a single interim analysis for safety and efficacy. Because AIS is a medical 
emergency, the trial is designed to enable the administration of standard-of-care treatments 
without delay in order to save the life of the person concerned, restore good health or alleviate 
suffering. 
Participants harboring an acute ischemic stroke who are selected for endovascular 
revascularization without intravenous or intra-arterial thrombolytic therapy will be given a single, 
2.6 mg/kg (up to a maximum dose of 270 mg) intravenous dose of nerinetide or placebo. 
Randomization will be stratified by time from stroke onset to randomization ≤ 4.5 hours (yes/no) 
and done with stochastic minimization to balance baseline factors within strata. The end of the 
main trial is defined as the date that the last enrolled participant has completed their Day 90 
visit/contact. For the purpose of an analytic follow-up sub-trial component, participants will be 
contacted by telemedicine or telephone at 1-Year by individuals blinded to the outcome of the 
main trial.   
A total of up to 850 male and female participants aged 18 years and older harboring AIS and who 
are selected for endovascular revascularization without intravenous or intra-arterial thrombolytic 
therapy will be enrolled.  
All participants in the main trial will be followed for 90 days (or until death if prior to 90 days).  
At Day 30 and Day 90 it is preferred that participants will return to clinic.  If an in-clinic visit is 
not possible the participant can be contacted by telemedicine (preferred) or by telephone (last 
option).  
Participants will be followed at 1-Year for the analytic sub-trial for further outcome assessment by 
telemedicine or telephone interview conducted by individuals blinded to the outcome of the main 
trial.  This sub-trial will be conducted to explore the independent functioning and quality of life at 
1-Year.   
Two database locks and corresponding reports are planned for this trial. The first report will be 
based on the completion of Day 90 visits for the main trial.  The second report will be following 
the completion of the 1-Year follow up for the analytic sub-trial.    
4.2 
Scientific Rationale for Study Design 
The rationale for the present trial is as follows: 
1) The ESCAPE-NA1 trial (protocol NA-1-007) provided promising evidence that, in 
participants with AIS who were selected for EVT and who did not receive thrombolysis, 
treatment with nerinetide increases functional independence and reduced stroke mortality12. 
This was supported by a reduction in infarction volume as measured by MRI or CT scanning. 
Since these improvements were observed in three separate domains of outcome (functional 
independence, mortality, and infarction volumes), they are unlikely to be due to chance 
alone. The present trial is intended to explore these findings further.  


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2) Participants in ESCAPE-NA1 who received thrombolysis as part of their care did not benefit 
from subsequently being administered nerinetide. The hypothesis explaining this lack of 
effect is that nerinetide in participants who received alteplase was cleaved by the protease 
plasmin. Plasmin is produced from circulating plasminogen by alteplase and persists for 
hours after alteplase treatment.  This hypothesis of nerinetide cleavage was supported by 
pharmacokinetic data from a subset of participants in ESCAPE-NA1 that showed that those 
who received thrombolysis had reduced plasma levels of nerinetide (approximately 60% 
reduction) as compared to participants who did not receive thrombolysis., Because 
nerinetide is a peptide drug, it was predicted to be cleaved by plasmin, though the magnitude 
of this effect in humans was unclear. Preclinical studies showed that plasmin cleaves 
nerinetide into several fragments beginning at its N-terminus. Additional preclinical studies 
then showed that co-administration of nerinetide with high-dose alteplase (6x the human 
dose) can nullify the neuroprotective effectiveness of nerinetide in a rat model of embolic 
middle cerebral artery occlusion (eMCAO). However, due to differences between human 
and rat fibrinolytic systems, the magnitude of the drug-drug interaction between alteplase 
and nerinetide, and its impact on the effectiveness of nerinetide in humans have not been 
anticipated from these animal studies. Section 4.3 provides further details regarding the 
justification of the target patient population for this trial as a result of these preclinical and 
clinical findings.  
3) Based on data from preclinical studies, the Phase 1 (protocol NA-1-001) safety trial, the 
Phase 2 ENACT trial23 (protocol NA-1-002) and the Phase 3 ESCAPE-NA1 trial12 (protocol 
NA-1-007), nerinetide is expected to be have an acceptable safety profile. 
4) There is a compelling need to develop neuroprotectants in order to increase the proportion 
of patients who may benefit from EVT. These agents could improve the outcomes of patients 
and render more patients with AIS into candidates for endovascular or pharmacological 
recanalization treatment.  
The current trial is intended to confirm the findings in the ESCAPE-NA1 study that nerinetide 
may improve functional independence, reduce mortality, and reduce infarction volumes in 
participants with AIS who are selected for EVT and who are not treated with thrombolytics. As 
such, it is a Phase 3, randomized, multicentre, blinded, placebo-controlled, parallel group, single-
dose design. Participants harboring an acute ischemic stroke who are selected for endovascular 
revascularization without intravenous or intra-arterial thrombolytic therapy will be given a single, 
2.6 mg/kg (up to a maximum dose of 270 mg) intravenous dose of nerinetide or placebo. 
Randomization will be stratified by time from stroke onset to randomization ≤ 4.5 hours (yes/no) 
and done with stochastic minimization to balance baseline factors within strata. 
The current trial is timely, in that it is evaluating an intervention that may mitigate the detrimental 
effects of slowdowns in emergency stroke care workflows caused by COVID-19 (see Section 
2.3.2). For example, if reperfusion is delayed by 30 minutes, the probability of a good outcome is 
reduced by 10.6%24 and perhaps up to 26%25. Treatment with nerinetide in patients who are not 
treated with thrombolysis improved good outcome by a similar degree in ESCAPE-NA112. 
The main differences between this trial (ESCAPE-NEXT) and ESCAPE-NA1 are that: 


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1) ESCAPE-NEXT focuses on participants who do not receive thrombolysis, in order to 
confirm the results in that patient population observed in ESCAPE-NA1 
2) The secondary outcomes in ESCAPE-NEXT focus on domains of clinical benefit other 
than functional outcome, namely mortality, rates of worsening of stroke and neurological 
function.  
3) ESCAPE-NEXT has an analytic 1-Year follow-up sub-trial investigating the long-term 
effects of nerinetide treatment.  
4.3 
Justification for the Target Study Population  
Nerinetide is being developed as a drug for use in emergency situations aimed at reducing global 
disability in patients with acute ischemic stroke.  Nerinetide is intended to enhance the outcome of 
patients who may benefit from EVT and add to the existing standard of care stroke treatments.   
Since the only approved pharmacological therapy for acute ischemic stroke is recombinant tissue 
plasminogen activator (rtPA; alteplase), NoNO has conducted several pre-clinical studies to 
evaluate and understand the drug-drug interaction between nerinetide and thrombolytic agents 
such as alteplase or tenecteplase. Nerinetide does not have fibrinolytic activity of its own, nor 
does it interfere with the activity of alteplase or tenecteplase in humans.  It has a plasma half-life 
of about 5-10 minutes after which it is redistributed to extravascular tissues. Because nerinetide is 
a peptide, it is cleaved by proteases. Nerinetide is shown to be cleaved by plasmin, a serine 
protease generated from the maturation of circulating plasminogen by tissue-plasminogen 
activators such as alteplase and tenecteplase.  In preclinical studies in-vitro, nerinetide levels in rat 
plasma were reduced by alteplase in a concentration-dependent manner, and the effect of a 
concentration of 22.5 µg/ml (intended to mimic the concentration of alteplase in humans during a 
clinical infusion) on lowering nerinetide levels was similar in magnitude between rat and human 
plasma. When given in-vivo, the co-administration of nerinetide with the human dose of alteplase 
(0.9 mg/Kg) resulted in a non- significant reduction of the Cmax and AUC of nerinetide. 
However, at six times the human dose (5.4mg/Kg) alteplase caused a significant lowering of the 
mean Cmax and AUC of nerinetide (49.5% and 44%, respectively). Details of these findings are 
summarized in the Investigator’s Brochure.   
NoNO’s previous Phase 3 trial (ESCAPE-NA-1) accounted for the existing standard of care stroke 
treatments, namely the use of alteplase, and the use of different thrombectomy devices, in 
accordance with institutional standards.  In anticipation of a possible drug-drug interaction 
between nerinetide and alteplase, the trial employed stratification based on the use of alteplase and 
the thrombectomy device, and a minimization approach randomization in a 1:1 ratio for nerinetide 
vs. placebo.  The ESCAPE-NA1 study provided significant evidence supporting an interaction 
between the use of alteplase and the efficacy of nerinetide. In the no-alteplase stratum, nerinetide 
was associated with improved outcomes, and in the alteplase stratum there was no observed 
benefit with the absolute risk difference slightly (non-significantly) favoring placebo. The 
biological plausibility of treatment effect modification by alteplase was supported by findings 
from PK sampling from subjects in the trial showing reductions in peak plasma nerinetide levels 
in subjects that received alteplase, as well as by the preclinical data that demonstrated the 
cleavage of nerinetide by alteplase in rat and human plasma and in-vivo in rats. Details of these 
findings are summarized in the Investigator’s Brochure.   


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Due to the clear and non-arbitrary findings of a drug-drug interaction between thrombolytics and 
nerinetide, it was decided that the current ESCAPE-NEXT study would focus its design on 
participants who are not treated with alteplase. Current stroke treatment guidelines26 recommend 
the use of thrombolysis only up to 4.5 hours after stroke onset, whereas the enrollment window 
for ESCAPE-NEXT is up to 12 hours. Additionally, a large proportion of stroke patients who 
present within the 4.5 hour window of alteplase do not qualify for thrombolysis due to various 
reasons27-29. Therefore, it is anticipated that the ESCAPE-NEXT trial will not interfere with 
clinical decisions made by the treating physicians, while addressing a substantial and important 
portion of patients with AIS who are selected for EVT. 
Because of this important distinction between subjects in the alteplase stratum vs the no-alteplase 
stratum in the previous ESCAPE-NA-1 study, the current study (ESCAPE-NEXT) is designed to 
address a population of adults 18 years and older harboring an acute ischemic stroke who are 
selected for endovascular revascularization without prior treatment with intravenous or intra-
arterial thrombolytic therapy.  
4.4 
Justification for Dose 
Nerinetide 2.6 mg/kg, up to a maximum of 270 mg (or matching placebo volume) is administered 
as a single approximately 10-minute intravenous infusion in the upper or lower extremity using an 
infusion pump initiated in the CT scan suite.  The 2.6 mg/kg dose was chosen for this clinical trial 
because of: 
1) the safety profile observed in the previous Phase 1, 2 and 3 clinical trials,  
2) the observed capacity of this dose of nerinetide to reduce stroke tissue damage and to 
improve neurological function in humans and non-human primates and  
3) the capacity of this dose to reduce stroke tissue damage and improve neurological damage 
in human participants undergoing endovascular repair of brain aneurysms as demonstrated 
in the phase 2 trial.  
4) the capacity of this dose to improve functional independence (mRS 0-2) as demonstrated in 
the Phase 3 trial 
4.5 
End of Study Definition 
The end of the study is defined as the date of the last contact of the last participant in the trial at 
the 1-Year follow up.   
Two database locks and corresponding reports are planned for this trial.  The first report will be 
based on the completion of Day 90 visits for the main trial.  The second report will be following 
the completion of the 1-Year follow up for the analytic sub-trial.  
 


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5 
STUDY POPULATION 
Prospective approval of protocol deviations to recruitment and enrollment criteria, also known as 
protocol waivers or exemptions, is not permitted. The study is designed to address a population of 
participants who are not deemed by the treating physician to be candidates for thrombolytic 
therapy according to current guidelines. The study population includes adults 18 years and older 
harboring an acute ischemic stroke who are selected for endovascular revascularization without 
prior treatment with intravenous or intra-arterial thrombolytic therapy.  This population is 
substantially similar to that in the ESCAPE-NA1 trial but excludes patients who received or are 
planned to receive prior thrombolysis.   
The decision to administer a thrombolytic is at the discretion of the treating physician 
independently of the trial. The treating physician is expected to follow standard of care guidelines, 
consider best medical evidence including any hypersensitivity reactions of the patient to the drug, 
and to use their clinical judgement in order to ensure the best care for their acute stroke patients.  
Patients who are deemed by the treating physician to benefit from thrombolysis, or are 
administered a thrombolytic prior to screening for any reason, will not be enrolled in 
ESCAPE- NEXT. If the patient is not selected for treatment with a thrombolytic the treating 
physician may consider the patient as a candidate for the trial. 
5.1 
Inclusion Criteria 
1) Acute ischemic stroke (AIS) selected for emergency endovascular treatment. 
2) Age 18 years or greater. 
3) Onset (last-known-well) time to randomization time within 12 hours.  
4) Disabling stroke defined as a baseline National Institutes of Health Stroke Score (NIHSS): 
a. NIHSS > 5 for internal carotid artery (ICA) and M1-middle cerebral artery (MCA) 
occlusion; or 
b. NIHSS > 10 for M2-MCA occlusion. 
5) Confirmed symptomatic intracranial occlusion at one or more of the following locations: 
Intracranial carotid I/T/L, M1 or M2 segment MCA.  Tandem extracranial carotid and 
intracranial occlusions are permitted. 
6) Pre-stroke (24 hours prior to stroke onset) independent functional status in activities of daily 
living with modified Barthel Index (BI) ≥ 95. Patient must be living without requiring nursing 
care. 
7) Qualifying imaging performed less than 2 hours prior to randomization. 
8) Consent process completed as per national laws and regulation and the applicable ethics 
committee requirements.  
5.2 
Exclusion Criteria 
1) Treated with a tissue plasminogen activator (e.g., alteplase or tenecteplase) within 24 hours 
before randomization  


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2) Determination by the treating physician, based on current treatment guidelines and medical 
evidence, that treatment with a plasminogen activator is indicated.  
3) Large core of established infarction defined as ASPECTS 0-4. 
4) Absent or poor collateral circulation on qualifying imaging (e.g., collateral score of 0 or 1). 
5) Any intracranial hemorrhage on the qualifying imaging. 
6) Planned use of an endovascular device not having approval or clearance by the relevant 
regulatory authority. 
7) Endovascular thrombectomy procedure is completed as defined by the presence of TICI 2c/3 
reperfusion or completion of groin / arterial closure. 
8) Clinical history, past imaging or clinical judgment suggesting that the intracranial occlusion is 
chronic or there is suspected intracranial dissection such that there is a predicted lack of 
success with endovascular intervention. 
9) Estimated or known weight > 120 kg (264 lbs). 
10) Pregnancy/Lactation; female, with positive urine or serum beta human chorionic gonadotropin 
(β-hCG) test, or breastfeeding. 
11) Known prior receipt of nerinetide for any reason, including prior enrolment in this ESCAPE-
NEXT trial. 
12) Severe known renal impairment defined as requiring renal replacement therapy (hemo- or 
peritoneal dialysis). 
13) Severe or fatal comorbid illness that will prevent improvement or follow up.  
14) Inability to complete follow-up treatment to Day 90.  
15) Participation in another clinical trial investigating a drug, medical device, or a medical 
procedure in the 30 days preceding trial inclusion. 
5.3 
Lifestyle Considerations 
No restrictions are required. 
5.4 
Screen Failures 
Screen failures are defined as patients who consent to participate in the clinical trial but are not 
subsequently randomized to be a trial participant. The informed consent form will be maintained 
at the study site, but these participants will not be entered in the CRF. 
5.5 
Study Enrolment Process 
In this acute stroke trial, participants should be randomized into the trial and receive study drug as 
soon as possible, following review of trial eligibility and the local informed consent process. 
Participants will be identified using usual standard of care screening methods at the acute stroke 
hospital. All participants will undergo an acute clinical assessment, blood laboratory assessment 
and baseline brain imaging.  


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If the participant remains eligible after completion of routine stroke screening, the patient will be 
consented (as required) and enrolled into the trial.  A participant is considered randomized the 
moment the randomization process is completed on-line.  Participants who are randomized but do 
not receive study drug will still be followed through the 90-day study period.  
5.5.1 Imaging 
The purpose of qualifying imaging is to identify a population of patients with stroke due to large 
vessel occlusion and to exclude patients with already malignant infarctions at baseline as those 
patients are predicted to lack or have small ischemic penumbras which are the targets of stroke 
therapy. The imaging criteria comprise a simple minimal standard set of qualifying imaging 
across the sites involved in the trial which are consistent with current standards of practice at the 
trial sites and stroke guidelines, to allow generalizability of the trial results30, 31.  
Minimum qualifying imaging is a NCCT and CTA with an imaging time from first slice NCCT to 
randomization time <= 120 minutes. mCTA is preferred but if it cannot be done, CTP or 
multimodal MR may be used instead. 
Instructions for the determination of the ASPECT score and collaterals scoring on CTA are 
provided at www.aspectsinstroke.com.   
Sites will only be selected to participate in the trial if they have established mechanisms for 
screening this population of participant.  This includes standard of care use of imaging. 
Patients will be included if they meet the following qualifying imaging criteria: 
• Non-contrast CT scan or MR-DWI scan with ASPECTS > 4, AND; 
• A proven anterior circulation intracranial occlusion (ICA, M1, M2) defined by CTA 
(preferred) or MRA; 
Patients will be excluded if they meet the following imaging criteria: 
• Direct or indirect evidence of poor pial collateral filling derived by any of the following: 
Direct pial collateral assessment 
1. mCTA evidence of poor pial collaterals – Tan score of 0 or 1  
2. spCTA evidence of poor pial collaterals if no mCTA is available–Tan score of 0 or 1 
3. dynamic mCTA (derived from CTP imaging acquisition) may be used if mCTA or 
spCTA is not available. 
Indirect pial collateral assessment 
1. If mCTA cannot be done collaterals may be assessed/inferred based upon perfusion 
imaging (CT perfusion or MR perfusion). As a guide if there is a match deficit 
(estimated core = estimated penumbra) collaterals are poor.  If there is a mismatch 
(estimated penumbra > estimated core) AND estimated core <70 cc, we infer that pial 
collaterals are adequate.  
If there is discordance between mCTA and the allowable alternate modalities, mCTA 
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5.5.2 Consent Process 
Participants or their legally authorized representative will be required to sign a statement of 
informed consent that meets the requirements of applicable national laws and regulation and the 
ethics committee. 
The investigator or his/her representative will explain the nature of the trial to the participant or 
his/her legally authorized representative and answer all questions regarding the trial. 
The medical record must include a statement describing under which process consent was 
obtained, and the timing of the consent and regained capacity consent. The authorized person 
obtaining the informed consent must also sign the informed consent form (ICF). 
See Appendix 10.6 for additional country specific details. 
Regained Capacity Consent 
If the original process involved anyone other than the participant, and if required by local 
standards, consent will be sought for the remaining procedures from the participant once they are 
deemed to have regained capacity.  Site staff will make ongoing efforts until: (1) regained 
capacity consent is obtained from participant as soon as it is possible and reasonable, (2) death, or 
(3) completion of the Day 90 assessment. 
In the event the participant dies prior to providing regained capacity consent, each site will have a 
plan to provide information about the clinical trial to the subject's LAR or family member. 
Amendment of the ICF 
In the event that new information is available and the ICF is amended, and if required by local 
Health Authorities and/or Ethics Committees, participants must be re-consented to the most 
current version of the ICF(s) during their participation in the trial. A copy of each ICF(s) must be 
provided to the participant or the participant’s legally authorized representative. 
Note: Electronic consent tools may be used for initial and regained capacity consent, as permitted 
under national laws and regulations and the applicable Independent Review Boards/Ethics 
Committee.  
5.5.3 Physical Examinations 
To support the assessment of inclusion and exclusion criteria and medical history, a stroke 
focused physical examination at baseline will include, at a minimum, assessments of the 
Neurological, Cardiovascular, Respiratory and Gastrointestinal systems. Investigators should pay 
special attention to clinical signs related to previous strokes.   
 
 


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6 
STUDY INTERVENTIONS and CONCOMITANT THERAPY 
6.1 
Study Intervention Administration 
Nerinetide was formulated at 20 mg/ml under current Good Manufacturing Practices by 
in 50 mM sodium phosphate buffer with 0.45% sodium 
chloride (NaCl), potential hydrogen (pH) 7.0.  This formulation was dispensed aseptically into 20 
mL single use vials with snap cap lids (13.5 mL) intended for a single-dose intravenous infusion 
of nerinetide.  
Placebo consists of the same buffer used for nerinetide with slightly higher NaCl content to adjust 
for equivalence of osmolality between drug product and placebo.  It is supplied in identical vials 
containing 13.5 mL of 50 mM sodium phosphate pH 7.0 (0.55% NaCl).  After dilution into the 
saline bag, the drug has been demonstrated to be stable for at least 5 hours. 
Formulated nerinetide and placebo will be provided to clinical trial sites in sterile, single-use 
individually labeled vials (serum vials) each with a unique five-digit identification number and 
will be stored at the clinical trial site at 2 to 8°C in a secure location with restricted access. 
Table 6-1: Study Interventions 
Nerinetide 
Placebo 
Test Product Name 
Nerinetide (NA-1) 
Placebo 
Type 
Drug 
Drug 
Dose Formulation 
Vial 
Vial 
Unit Dose 
Strength(s) 
2.6 mg/kg 
Placebo 
Dosage Level(s) 
Single 
Single 
Route of 
Administration 
IV Infusion 
IV Infusion 
Use 
Investigational 
Placebo 
Sourcing 
Provided centrally by the Sponsor 
Provided centrally by the Sponsor 
Packaging and 
Labeling 
Study Intervention will be provided in a 
20 mL vial.  Vials will be packaged in 
boxes of multiple vials labeled as 
required per country requirements. 
Study Intervention will be provided in 
a 20 mL vial. Vials will be packaged in 
boxed of multiple vials labeled as 
required per country requirements. 
6.2 
Preparation/ Handling/ Storage/ Accountability 
Only participants enrolled in the trial may receive study intervention and only authorized site staff 
may supply or administer study intervention.  Study drug dosing will be carried out by, or under 
the supervision of, the investigator who is supervising the care of the participant for the planned or 
ongoing endovascular reperfusion procedure.  
As soon as the participant is deemed eligible for the trial, the investigator (or delegate) will log into 
the central randomization website to receive the assigned vial number. 
Dose timing starts at the time of infusion onset.  Study drug is intended to be administered as soon 
as possible after randomization (i.e., 15 minutes).  
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A syringe for each individual participant’s dosing will be prepared by calculating the volume to 
draw from the vial as follows:  
• for participants weighing less than 105 kg: (2.6 mg/kg x participant weight in kg)/(20 
mg/ml).  This will determine the number of mL to pull up into the syringe.   
• for participants weighing 105-120 kg the full volume of one vial (13.5mL, equivalent to 
270 mg of nerinetide) will be used. 
Estimated or actual weight can be used to calculate the study drug dosage. 
The syringe containing study drug will be injected into the intravenous port of a 50 or 100 mL 
drip bag of 0.9% normal saline that has been labeled with the randomization number.  The bag 
will be mixed by squeezing and inverting the bag several times.  Study drug should be infused 
into the participant as soon as practical. 
Dosing will be performed by administering the contents of the bag of study drug to the participant 
through an intravenous catheter inserted into a vein in the upper or lower extremity and using a 
standard infusion pump. Dosing will be carried out evenly over the course of 10 ± 1 minutes. The 
entire volume (treatment dose) of the intravenous bag must be administered. 
After the dose administration, a minimum of 10 mL of saline will be administered using the infusion 
pump, to flush any remaining medication left within the intravenous tubing. 
6.2.1 Storage and Accountability 
All study drug must be stored in a secure, temperature controlled (2 to 8 °C), and monitored 
(manual or automated) area in accordance with the labeled storage conditions with access limited 
to the investigator and authorized site staff.  Temperatures will be monitored using a device that 
can continuously monitor and record temperature readings. 
The investigator is responsible for study drug accountability, reconciliation, and record 
maintenance (i.e., receipt, reconciliation, and final disposition records).  Any expired, lost, 
damaged or out-of-specification study drug must be properly documented and reported to the 
Sponsor.  Further guidance and information for the final disposition of unused study drug are 
provided in the Operating Guideline. 
6.2.2 Disposition of Study Drug Supplies 
After study drug preparation, any remaining material in the vial will be labeled as “used,” and the 
volume removed will be documented (value in mL).  Vials labeled as “used” will be retained in a 
separate storage container than the unused vials.  Used vials will be disposed of on site, once the 
monitor (CRA) has completed the study drug monitoring and accountability.  Unused vials will be 
disposed of on site or returned to the sponsor after they have been monitored by the sponsor or 
sponsor’s representative. Destruction of unused vials at the study site will be documented and 
conducted in accordance with the site’s policies and procedures. 
 
 


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6.3 
Measures to Minimize Bias: Randomization and Blinding 
All participants will be centrally assigned to a randomized study intervention (i.e., nerinetide or 
placebo) using an Interactive Web Response System (IWRS). The login information and 
directions for the IWRS will be provided to each site.  The IWRS website will allocate the 
participant number and vial number. 
Treatment allocation will be assigned using 1:1 randomization (nerinetide:placebo) with a 
stratification based on time from stroke onset to randomization of ≤4.5 hours (yes/no) and a 
randomized minimization algorithm to minimize the contribution of imbalances in baseline factors  
(age, sex, baseline NIHSS score, baseline ASPECT score, occlusion location, time from 
qualifying imaging to randomization, and site). Randomization will be conducted centrally, using 
a web-based algorithm with treatment assignment allocated by web-based real-time interaction 
with the site. Randomized allocation will be fully concealed by having both dynamic real-time 
allocation based upon random number generation and blinded by the use of visually identical 
appearing nerinetide and placebo vials.  All vials will have a unique vial number. 
The purpose of minimization on the variables is to balance these variables across treatments and 
within strata to ensure a reduced chance that any observed effect size of nerinetide vs. placebo is 
confounded by these known important prognostic variables. This randomized minimization 
method from Zhao et al, called the minimal sufficient balance method32, will be used to ensure 
that the participants entered into the trial will be balanced between control (placebo) and active 
treatment (nerinetide) arms. 
All participants, investigators, their clinical staff, local and central laboratories, the clinical 
coordinating centre, the data management group, and the sponsor staff and delegates will be 
blinded to the randomization codes. 
6.3.1 Procedure for Breaking the Randomization Code 
In case of an emergency, the investigator has the sole responsibility for determining if the 
unblinding of a participant’s intervention assignment is warranted. Participant safety must always 
be the first consideration in making such a determination. If the investigator decides that 
unblinding is warranted, the investigator should make every effort to contact the sponsor prior to 
unblinding a participant’s intervention assignment unless this could delay emergency treatment of 
the participant. If a participant’s intervention assignment is unblinded, the sponsor must be 
notified within 24 hours after breaking the blind. The date and reason that the blind was broken 
must be recorded in the source documentation as applicable. 
To maintain the overall quality and legitimacy of the clinical trial, code breaks should occur only 
in exceptional circumstances when knowledge of the actual treatment is absolutely essential for 
further management of the patient to ensure their safety and well-being. 
In case of emergency, a rapid unblinding procedure is available to investigators.  The investigator 
will contact the randomization provider to request unblinding of the specific participant. The 
randomization provider will respond in writing to the investigator only with the unblinded patient 
treatment allocation. 
Only the investigator requesting the unblinding will receive the unblinding information.  The 
Investigator is requested to maintain the blind as far as possible. The actual treatment allocation 


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should not be disclosed to the participant and/or other site personnel unless, in the judgement of 
the investigator, this information is required for the participant’s safety. The actual treatment 
allocation must not be disclosed to study personnel on site not involved in the participant’s 
medical care, to monitors or the sponsor. 
In order to fulfill expedited regulatory reporting requirements, the Sponsor may be required to 
unblind the participant if the SAE meets the criteria for reporting to health authorities.  The 
Sponsor’s independent third party will initiate the request that the participant’s treatment group be 
unblinded.  In this case, the code will be broken only for the participant(s) in question. The 
information resulting from code-breaking (i.e., the participant’s treatment allocation) will not be 
communicated to either the Investigator or the Sponsor. 
Otherwise, randomization data will be kept strictly confidential, accessible only to authorized 
persons, until the time of unblinding after database lock at the time of interim analysis and at end 
of the study (Day 90). For the ongoing 1-Year follow up, site staff conducting the assessments 
will remain blinded until after the 1-Year follow up database lock. 
6.4 
Study Intervention Compliance 
Study drug will be dispensed under the instructions of the investigator or designee and under 
medical supervision.  The date and time of dose administered will be recorded in the source 
documents and in the CRF.  The dose of study drug and study participant identification will be 
confirmed at the time of dosing by a member of the study site staff other than the person 
administering the study drug.  The investigator may terminate study drug administration at his/her 
discretion. 
6.5 
Dose Modification 
Not applicable in this single-dose trial. 
6.6 
Continued Access to Study Intervention after the End of the Study 
Not applicable in this single-dose trial. 
6.7 
Treatment of Overdose 
For this trial, any dose of study drug greater than 150% of the planned dose will be considered an 
overdose. 
The sponsor does not recommend specific treatment for an overdose. In the event of an overdose, 
the investigator should: 
1) Contact the Drug Safety Department (sae@nonoinc.ca) immediately. 
2) Closely monitor the participant for any AEs/SAEs and laboratory abnormalities for at least 
1 day.  
3) Document the quantity administered in the CRF. 


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6.8 
Concomitant Therapy 
There are no restricted medications once a participant is enrolled in this trial.  Any medication or 
vaccines (including over-the-counter or prescription medicines) that the participant is receiving at 
the time of enrollment (within 24 hours prior) or receives up to Day 6 must be recorded along 
with: 
• Dates of administration including start and end dates, medications that were ongoing at the 
last contact will be updated with a stop date or confirmed as ongoing. 
• Indication for use. 
6.8.1 Rescue Medicine/Treatment 
6.8.1.1 Early Study Drug Cessation 
The intervention is the intravenous administration of 2.6 mg/kg (up to a maximum of 270 mg) of 
nerinetide over a 10 ± 1 minute intravenous infusion to participant undergoing endovascular 
mechanical thrombolysis/thrombectomy.  It is expected that dosing will be completed before the 
endovascular procedure is completed. However, if dosing is ongoing during the endovascular 
procedure, dosing will not be stopped in the event of an adverse intra-procedural event deemed to 
be a complication of the endovascular intervention. 
The investigator may terminate drug administration at his/her discretion. 
6.8.1.2 Treatment of Hypotension  
If hypotension (systolic < 80 mmHg; or any level of decreased BP that the physician deems to be 
clinically relevant) is observed in a participant, the hospital physician will be instructed, at his/her 
discretion, to administer any medication that they deem to be required for the participant’s health 
and safety. 
There is no specific treatment requirement related to treating hypotension that may be observed in 
participants with stroke who are also receiving nerinetide. Treatment of hypotension in this setting 
may include all or some of the following, as appropriate, and at the hospital physician’s 
discretion. 
First, the physician will determine if hypotension is symptomatic.  Asymptomatic participants 
may be observed for spontaneous recovery. 
• Treatment, if required, should include fluid resuscitation with crystalloid fluid (e.g., 0.9% 
saline) and/or vasopressors, if needed. 
• Consider treatment with antihistamine agents (diphenhydramine 50 mg IV, ranitidine 
50mg IV) and corticosteroids (e.g., Decadron™; 10 mg IV) if the reaction is severe.   
• Consider using subcutaneous or intravenous epinephrine.  
• If bronchospasm or laryngospasm are important additional symptoms, consider treatment 
with inhaled racemic epinephrine. 
Specific amounts and doses of intravenous fluids or other drugs administered are left to the 
medical judgment of the hospital physician. 


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All participants will be monitored closely for these and other potential complications throughout 
the clinical trial.  All participants will receive standard medical care as per local practice.  If 
hypotension as defined above occurs, the hypotension and its treatment are to be recorded as an 
AE in the CRF. 
6.9 
Endovascular Intervention and Stroke Care 
EVT should be conducted as per the local protocol and in compliance with the current treatment 
guidelines such as those published by the American Heart Association (AHA). 
All acute stroke participants should receive the best standard of care according to current 
treatment guideline and any national guidelines (e.g., Canadian best practices guidelines for acute 
stroke care, European Stroke Organization, etc.).  All participants are expected to be admitted to 
hospital as part of routine standard of care.  All participants are expected to receive expert stroke 
unit care and then rehabilitation according to their clinical need through the full 90 days. 
 
 


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7 
DISCONTINUATION of STUDY INTERVENTION and PARTICIPANT 
DISCONTINUATION/WITHDRAWAL 
7.1 
Discontinuation of Study Intervention 
In rare instances, it may be necessary for a participant to permanently discontinue (definitive 
discontinuation) study intervention. If study intervention is definitively discontinued, the 
participant will remain in the trial and be evaluated to Day 90. 
7.2 
Participant Discontinuation/Withdrawal from the Trial 
Participation in this clinical trial may be discontinued for any of the following reasons: 
• Administrative reasons (uncooperative, noncompliant, etc.) 
• Participant’s decision not to participate any further 
• If it is in the participant’s best interest, per the qualified/principal or sub-investigator 
If the participant or legally authorized representative (LAR) withdraws consent, participant data 
will be included in the analysis up to the date of the consent withdrawal and this withdrawal of 
consent will be documented in the CRF. 
If the LAR has originally provided consent and the participant subsequently declines consent, this 
will be deemed to be a withdrawal of consent. The investigator and sponsor would continue to 
have access to data that have already been collected. 
A participant may not withdraw use of his or her data that have already been collected, this is in 
alignment with the FDA guidance document “Data Retention When Participants Withdraw from 
FDA-Regulated Clinical Trials”, which is based on the importance of avoiding selection biases 
that could compromise the analysis of the overall trial. 
Otherwise, all randomized participants will continue to be followed according to protocol 
requirements and follow-up data will be included in the analysis.  Criteria for removal of 
participants will be recorded and reported. 
7.3 
Lost to Follow up 
A participant will be considered lost to follow-up if he or she repeatedly fails to return for scheduled 
visits/contacts and is unable to be contacted by the study site.  The following actions must be taken 
if a participant fails to return to the clinic or if they cannot be contacted by phone for a required 
study visit: 
• The site must attempt to contact the participant and reschedule the missed visit/contact as 
soon as possible and counsel the participant on the importance of maintaining the assigned 
visit schedule and ascertain whether or not the participant wishes to and/or should continue 
in the trial. 
• Before a participant is deemed lost to follow up, the investigator or designee must make 
every effort to regain contact with the participant (at a minimum 3 telephone 
calls/contacts). These contact attempts should be documented in the participant’s study 
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• Should the participant continue to be unreachable, he/she will be considered to have 
withdrawn from the trial.  
• Site personnel will attempt to collect the vital status of the participant within legal and 
ethical boundaries for all participants randomized, including those who did not get study 
intervention. Public sources may be searched for vital status information.  If vital status is 
determined as deceased, this will be documented and the participant will not be considered 
lost to follow-up. Sponsor personnel will not be involved in any attempts to collect vital 
status information. 
 
 


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8 
STUDY ASSESSMENTS and PROCEDURES 
Study procedures and their timing are summarized in the Schedule of Activities. Adherence to the 
trial design requirements is essential and required for study conduct. 
Procedures conducted as part of the participant’s routine clinical management (e.g., blood count) 
and obtained before signing of the ICF may be utilized for baseline purposes provided the 
procedures met the protocol-specified criteria and were performed within the time frame defined 
in the Schedule of Activities. 
8.1 
Efficacy Assessments 
Planned time points for all efficacy assessments are provided in the Schedule of Activities. 
8.1.1 The Modified Rankin Scale 
The primary endpoint used in this trial will be global disability, as measured by the mRS, at Day 
90. The mRS is a valid and reliable clinician-reported measure of global disability that has been 
widely applied for evaluating recovery from stroke. It is a scale used to measure functional 
recovery (the degree of disability or dependence in daily activities) of people who have suffered a 
stroke33, 34. mRS scores range from 0 to 6, with 0 indicating no residual symptoms; 5 indicating 
bedbound, requiring constant care; and 6 indicating death.  
The post dose mRS will be obtained at Day 6 (or discharge), Day 30 and Day 90 and at the 1-Year 
follow up.  Premorbid mRS status may be obtained at any time, but ideally at the Day 1 or 2 visit.  
The mRS will only be scored by those trained and certified (via www.healthcarepoint.com) in the 
use of this scale.  An Electronic Clinical Outcome Assessment (eCOA) tool may be used to 
conduct this assessment. 
8.1.2 Mortality Rate 
Mortality status will be obtained at all visits during the 90-day study period and at the 1-Year follow 
up. 
8.1.3 Worsening of Stroke 
Worsening of stroke is defined as (A) progression, or hemorrhagic transformation, of the index 
stroke as documented by medical imaging that is (a) life-threatening requiring intervention and/or 
(b) results in increased disability as gauged by a ≥4 point increase from lowest NIHSS during 
hospitalization or (B) results in death from the index stroke.  
8.1.4 Volume of Strokes 
Prior to database lock at 90 Days, the total lesion volume of stroke as measured by MRI or CT 
brain images (MRI preferred) in nerinetide versus placebo control participants will be calculated 
from the Day 2/3 imaging. Where MRI is not available, infarct volumes will be determined from 
the Day 2/3 CT scan. The plan for combining CT and MRI data will be detailed in the Imaging 
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8.1.5 The National Institutes of Health Stroke Scale 
The NIHSS is a standardized neurological examination score that is a valid and reliable measure 
of disability and recovery after acute stroke35.  Scores range from 0 to 42, with higher scores 
indicating increasing severity. The scale includes measures of level of consciousness, extra ocular 
movements, motor and sensory tests, coordination, language and speech evaluations.  The NIHSS 
will be administered at Baseline, Post-EVT (2 Hours), Day 2, Day 6 (or discharge), Day 30 and 
Day 90. The NIHSS will only be scored by those trained in the use of this scale. An eCOA tool 
may be used to conduct this assessment. 
8.1.6 Barthel Index 
The BI is an index of functional independence36 that is a valid measure of activities of daily living 
when employed in stroke trials37.  Modified BI scores range from 0 to 100, with higher scores 
indicating greater independence in activities of daily living and mobility. The BI will be scored at 
Baseline (pre-morbid), Day 30 and Day 90 and at the 1-Year follow up, by those trained in the use 
of this scale.  Note that the original Barthel Index was a scale from 0-20.  The modified Barthel 
index simply multiplies the original scale by 5 to provide a 100-point score.  
8.1.7 EQ-5D-5L 
The EQ-5D-5L is a generic instrument for describing and valuing health. It is based on a 
descriptive system that defines health in terms of five dimensions: Mobility, Self-Care, Usual 
Activities, Pain/Discomfort, and Anxiety/Depression38. Each dimension has five response 
categories corresponding to: no problems, slight, moderate, severe and extreme problems39. The 
version of the instrument selected for the trial is interviewer administered either in-person, or by 
telemedicine or by telephone. The respondents will also rate their overall health on the day of the 
interview on a 0–100 visual analogue scale (EQ-VAS). The EQ-5D-5L will be administered at the 
Day 90 and at the 1-Year follow up by those trained in the use of this scale. An eCOA tool may be 
used to conduct this assessment. 
8.2 
SAFETY ASSESSMENTS 
Planned time points for all safety assessments are provided in the Schedule of Activities. 
8.2.1 Vital Signs 
Blood pressure and heart rate will be taken at Baseline (pre-dose), at the completion of drug 
infusion and Day 2.  Results taken from standard of care assessment/timepoints may be used. 
Temperature will be taken at baseline (if available per standard of care) and Day 2.  Clinically 
significant findings post-dose will be reported as AEs. 
8.2.2 Clinical Safety Laboratory Assessments 
Blood work will be taken at baseline and at Day 2 including: CBC (hemoglobin, platelets and 
hematocrit), electrolytes (sodium, potassium, chloride), serum creatinine and serum glucose and 
assessed by the local laboratory.  Results from local standard of care testing may be used. A 
central lab will not be used.  Due to the short time-period from arrival at hospital and the EVT, the 
results of the baseline blood work are not required prior to randomization.  Baseline results from 


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primary hospital (within 8 hours) are accepted, if written documentation is available.  Clinically 
significant laboratory findings from the Day 2 sample (post dose) will be reported as AEs. 
8.2.3 Pregnancy Testing 
If the participant is female and is of childbearing potential, a pregnancy test (urine or serum point-
of-care pregnancy test) must be completed at baseline prior to inclusion into the trial. 
8.3 
Adverse Events (AEs), Serious Adverse Events (SAEs), and Other Safety Reporting 
The definitions of an AE or SAE can be found in Appendix 3: Adverse Events: Definitions and 
Procedures for Recording, Evaluating, Follow-up, and Reporting. 
AEs will be reported by the participant (or, when appropriate, by a healthcare provider, caregiver, 
surrogate, or the participant’s legally authorized representative).  The investigator and any 
qualified designees are responsible for detecting, documenting, and recording events that meet the 
definition of an AE or SAE and remain responsible for following up AEs that are serious, 
considered related to the study intervention or study procedures, or that caused the participant to 
discontinue the trial. 
Adverse events of special interest (AESIs) include any AEs which occur within 2 hours of end of 
study drug infusion and which fall under the standardized MedDRA queries of “Angioedema”, 
“Anaphylactic reaction”, and “Anaphylactic shock” as well as a list of MedDRA terms relating to 
“Hypotension”. 
The method of recording, evaluating, and assessing causality of AEs, AESI and SAEs and the 
procedures for completing and transmitting SAE reports are provided in Appendix 3. 
8.3.1 Time Period and Frequency for Collecting AE and SAE Information  
All SAEs will be collected from the start of study drug administration until Day 90, in addition 
SAE assessed as related to study drug, or have a fatal outcome will be collected to Day 90, see the 
Schedule of Activities. 
All AE will be collected from the start of study drug administration until Day 30   at the time 
points specified in the Schedule of Activities. 
Medical occurrences that begin before the start of study intervention but after enrolment into the 
trial will be recorded on the Medical History section of the electronic case report form (CRF) not 
the AE section. 
All SAEs will be recorded and reported to the sponsor or designee immediately, without undue 
delay, under no circumstances later than 24 hours following the knowledge of such an event, as 
indicated in Appendix 3. The investigator will submit any updated SAE data to the sponsor within 
24 hours of it being available. 
8.3.2 
Method of Detecting AEs and SAEs 
Care will be taken not to introduce bias when detecting AEs and/or SAEs. Open-ended and 
non-leading verbal questioning of the participant is the preferred method to inquire about 
AE occurrences.  A consistent methodology of eliciting AEs at all participant evaluation 
timepoints will be used.  Non-directive questions include: 


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• How have you felt since your last clinical visit/hospital discharge? 
• Have you had any new or changed health problems since you were last here? 
• Have you had any unusual or unexpected worsening of your underlying medical condition 
or overall health? 
• Have there been any changes in the medicines you take since your last clinical visit/hospital 
discharge? 
AE identification while the participant is admitted to the acute stroke hospital will be collected via 
acute stroke hospital patient records and verbal histories from the participant or LAR.  For follow 
up visits after discharge from the acute stroke hospital the participant (or LAR if the participant is 
not able to respond to the questions) will be asked about the occurrence of AEs since the last 
contact, and if available, from records at the acute stroke hospital. 
Diagnosis versus signs and symptoms for the purpose of AE reporting: if known at the time of 
reporting, a diagnosis should be reported rather than individual signs and symptoms (e.g., record 
only pneumonia rather than pyrexia, coughing, shortness of breath).  However, if a constellation 
of signs and/or symptoms cannot be medically characterized as a single diagnosis it is acceptable 
to report the information that is ultimately available. 
8.3.3 Follow-up of AEs and SAEs 
After the initial AE/SAE report, the investigator is required to proactively follow each participant 
at subsequent visits/contacts. All SAEs will be followed until resolution, stabilization, the event is 
otherwise explained, or the participant is lost to follow-up (as defined in Section 7.3). Further 
information on follow-up procedures is given in Appendix 3. 
AEs that were ongoing at the last contact will be updated with a stop date or confirmed as 
ongoing.  AE collection will continue until Day 30, and SAE to Day 90 or the final contact. 
Investigators are not obligated to actively seek AE or SAE after conclusion of the study 
participation. However, if the investigator learns of any SAE, including a death, at any time after a 
participant has been discharged from the study, and he/she considers the event to be reasonably 
related to the study intervention or study participation, the investigator must promptly notify the 
sponsor. 
8.3.4 Regulatory Reporting Requirements for SAEs 
Prompt notification by the investigator to the sponsor of a SAE is essential so that legal 
obligations and ethical responsibilities towards the safety of participants and the safety of a study 
intervention under clinical investigation are met. 
The sponsor has a legal responsibility to notify both the local regulatory authority and other 
regulatory agencies about the safety of a study intervention under clinical investigation. The 
sponsor will comply with country-specific regulatory requirements relating to safety reporting to 
the regulatory authority, Institutional Review Boards (IRB)/Independent Ethics Committees 
(IEC), and investigators. 


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Investigator safety reports must be prepared by the sponsor for suspected unexpected serious 
adverse reactions (SUSAR) according to local regulatory requirements and sponsor policy and 
forwarded to investigators as necessary. 
The Sponsor’s Drug Safety Department will notify the Investigators in writing of the occurrence of 
any reportable SAEs.  The Sponsor or delegate will be responsible for reporting SUSARs to any 
Central Ethics Committees in compliance with local current legislation.  The Investigators will be 
responsible for informing their local ethics committees of any reportable SAEs as per their local 
requirements. 
An investigator who receives an investigator safety report describing a SAE or other specific 
safety information (e.g., summary or listing of SAEs) from the sponsor will review and then file it 
along with the Investigator’s Brochure and will notify the IRB/IEC, if appropriate according to 
local requirements. 
8.3.5 Pregnancy 
Details of all pregnancies in female participants and female partners of male participants will be 
collected after the start of study intervention and until Day 30. 
If a pregnancy is reported, the investigator should inform the sponsor within 24 hours of learning 
of the pregnancy and should follow the procedures outlined in Section 10.4 (Appendix 4: 
Collection of Pregnancy Information). 
Pregnancy itself is not considered an AE, but any complications during pregnancy are to be 
considered as AEs, and in some cases, could be considered SAEs. Spontaneous abortions, fetal 
death, stillbirth, and congenital anomalies reported in the baby are always considered as SAEs, 
and the information should be provided to the Sponsor regardless of when the SAE occurs (e.g., 
even after the end of the trial). 
8.4 
Pharmacokinetics 
Blood samples of approximately 5 mL will be collected for measurement of plasma 
concentrations of nerinetide as specified in the Schedule of Activities. Samples will be collected 
from up to 100 participants enrolled in Canada and the US. A total of five 5 mL blood samples 
will be drawn during the Baseline Visit (V1).  Time (T) =0 being the initiation of dosing of study 
drug or placebo.  Samples should be drawn at the following timepoints: 
Sample 1: post randomization & prior to start of study drug administration  
Sample 2: 10 minutes from start of study drug administration (Time = within 1 min of study 
drug completion) 
Sample 3: 20 minutes from start of study drug administration (Time = 15 to 25 min) 
Sample 4: 30 minutes from start of study drug administration (Time = 26 to 45 min) 
Sample 5: 60 minutes from start of study drug administration (Time = 46 to 120 min) 
Sample collection method should be the least invasive to the participant and may be combined 
with routine blood sampling.  Instructions for the collection and handling of biological samples 


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will be provided by the sponsor. The actual date and time (24-hour clock time) of each sample 
will be recorded. 
Each plasma sample will be divided into 2 aliquots (1 each for primary and a back-up).  The 
samples will be handled per guidelines/instructions provided by the sponsor.  During storage, PK 
tubes will be kept in a freezer at -10°C or colder. 
The plasma samples will be processed for pharmacokinetics analyses.  Appropriate firewalls will 
be put in place to prevent unblinding.  Results of the analysis will not be provided to the sponsor 
until after database lock. Genetic analyses will not be performed on these samples. Participant 
confidentiality will be maintained.  Samples may be stored for a maximum of 15 years (or 
according to local regulations) following the last participant’s Day 90 visit at a facility selected by 
the sponsor 
 
 


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9 
STATISTICS 
9.1 
Sample Size Determination 
The primary estimand will be the adjusted difference in the mRS response (i.e., mRS score of 0-2) 
proportions between treatment conditions (nerinetide vs. placebo) in the target patient population 
at Day 90. Participants with mRS score of 0-2 are defined to be responders. Deaths occurring over 
the Day 90 period will be considered as non-responses.   
Primary hypothesis test and 95% confidence interval estimate for the primary estimand will be 
provided by the analytic method of Ge, 201140 discussed in FDA’s most recent draft guidance 
Adjusting for Covariates in Randomized Clinical Trials for Drugs and Biological Products41, 
adjusting for the stratification covariate of time from stroke onset to randomization ≤ 4.5 hours 
(yes/no) and the randomized minimization factors (age, sex, baseline NIHSS score, baseline 
ASPECT score, occlusion location, time from qualifying imaging to randomization and pooled 
site), and an interaction term of treatment by time from stroke onset to randomization. If the 
interaction term is not significant at the level of 0.05, it will be removed from the model.  
Up to 850 male and female participants aged 18 or older harboring AIS and who are selected for 
endovascular revascularization without intravenous or intra-arterial thrombolytic therapy will be 
enrolled. 
Based on results of ESCAPE-NA1 and assuming a 50% overall responder rate for the placebo 
group, there will be approximately 91.3% power to detect an 11.4% absolute effect difference 
between response rate (proportion of responders, with Day 90 mRS in the range 0 to 2) with 
nerinetide and placebo, at alpha level 0.025 one-sided (0.05 2-sided), using the planned sample 
size of 850 evaluable subjects, randomized 1:1, per group [EaST v6.5, 2022]. 
This sample size was calculated taking into account a dropout/non-evaluable rate of 2% with a lag 
to primary endpoint assessment of 4 months, estimated accrual rate of 50 participants per month, 
target effects 0.5 vs 0.6114 and a single interim analysis for early superiority stopping with an 
O'Brien-Fleming alpha spending function boundary at 60% information (510 evaluable 
participants).  The interim analysis is planned to take place at 60% information (primary 
endpoint), i.e. when approximately 510 of the target 850 patients have reached their primary 
endpoint assessment. The cumulative alpha spent at the interim analysis is 0.004 and final analysis 
0.025, one-sided (0.05 2-sided); the stopping boundaries on the Z scale are 2.668 (interim) and 
1.981 (final) and on the p-value scale 0.004 (interim) and 0.021 (final), all on the assumption that 
the interim is conducted at 60% information. 
See Section 9.4 for further details on the interim analysis.   
9.2 
Analysis Sets 
For purposes of analysis, the following populations are defined: 
Population 
Description 
Enrolled  
All participants randomized into the trial. 
Randomly Assigned to Study 
Intervention 
All participants who received a dose or partial dose of study drug 


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Intent to Treat (ITT) 
All participants randomized into the trial with grouping by randomized 
treatment, regardless of treatment actually received.  Participant grouped 
according to the randomized (intended) treatment. 
Per Protocol (PP) 
All participants randomized and treated, with no major protocol 
deviations including: did not meet inclusion/exclusion criteria, did not 
receive planned dose volume, incorrect study drug vial, infusion more 
than 15 minutes, consent not obtained.  
Safety 
All participants randomly assigned to study intervention and who receive 
any volume of study drug.  Participants will be analyzed according to the 
intervention they actually received. 
The primary efficacy estimand analysis will be conducted in the ITT population.  The primary 
efficacy estimand analysis will be repeated on the Per Protocol (PP) population.  An ITT analysis 
will also be conducted for the secondary endpoint estimands, with participant grouped according 
to the randomized (intended) treatment.   
9.3 
Statistical Analysis 
The statistical analysis plan will be finalized prior to any interim analysis and it will include a 
more technical and detailed description of the statistical analyses described in this section. In the 
event that there are any inconsistencies between this protocol and the statistical analysis plan, the 
statistical analysis will be conducted as per the statistical analysis plan. This section is a summary 
of the planned statistical analyses of the most important estimand endpoints including primary and 
key secondary endpoints. 
9.3.1 General Considerations 
All imputed values will be determined prior to database lock and conducting primary analyses via 
rules documented prospectively in the final Statistical Analysis Plan for the study.  
Deceased participant will score 6 on the mRS, 42 on the NIHSS and 0 on Barthel Index and be 
counted as non-responders.  Every effort will be made to keep missing data, particularly the Day 
90 outcome assessments, to a minimum.  
For the primary analysis, for participants who are missing the mRS at Day 90: 
• if the participant is known to be dead at Day 90, they will be considered to be a non-
responder and the mRS will be imputed as 6 
• if the mRS was obtained at the Day 30 assessment or later, it will be carried forward as the 
Day 90 mRS value  
• if both the Day 30 and Day 90 mRS scores are missing but the participant is documented 
to be alive at Day 90 they will be considered to be a non-responder and the mRS will be 
imputed as a 5 
• if both the Day 30 and Day 90 mRS scores are missing and the mortality status of the 
participant is unknown at Day 90 they will be considered to be a non-responder and the 
mRS will be imputed as a 6. 


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If more than 5% subjects randomized are missing the mRS score at Day 90, additional imputation 
methods will be employed- details of which will be included in the SAP. 
For the secondary analysis of rate of mortality, for participants for whom the morality status is not 
known at Day 90: 
• if they were alive at Day 30, then the subject will be imputed as alive at Day 90   
• If both the Day 30 and Day 90 mortality is status is missing, the participant will be 
imputed as Dead at Day 90.  
For other analyses involving the mRS (other than mortality), the same imputation approach will 
be taken as for the primary analysis. No imputation will be done on the missing one-year follow-
up mortality data. 
A number of events may occur after study drug initiation and during the 90-day trial observation 
period that could impact data completeness, the interpretation of, or the ability to observe, each 
outcome variable. Details of handling of such events, which may or may not meet the ICH 
definition of intercurrent events (IEs)42, will be provided in the SAP. 
Participants who are missing NIHSS or BI endpoint data at Day 90 will have the last recorded 
score carried forward, provided that this score was obtained at the Day 30 visit or later. Otherwise, 
the missing NIHSS or BI will be imputed to the median score obtained at Day 90 in the trial. 
Sensitivity analyses using various imputation techniques will be specified prospectively in the 
SAP before the database lock for the interim analysis if more than 5% of participants randomized 
are missing the primary endpoint. 
Unless otherwise noted, categorical data will be summarized for each treatment group using 
counts and percentages, with the denominator for percentages being the number of participants in 
the population of interest. Unless otherwise noted, continuous data will be summarized for each 
treatment group using the number of observations (n), mean, standard deviation (SD), median, 
minimum, and maximum. Some continuous data will be reported as the median, interquartile 
range (IQR), minimum and maximum according to the clinical meaning of the data. 
Percentages will be rounded to one decimal place, except 0% and 100% will be displayed without 
any decimal places. Minima and maxima will be rounded to the precision of the original value; 
means and medians will be rounded to one decimal place greater than the precision of the original 
value; SDs will be rounded to two decimal places greater than the precision of the original value. 
P-values will be reported to four decimal places (0.xxxx), with values less than 0.0001 presented 
as <0.0001. 
Inferential analyses will generally include statistics such as 2-sided 95% confidence intervals (CI), 
and p-values. Unless stated otherwise, all statistical tests will be one-sided 0.025 (2-sided 0.05). 
In order to avoid sparse sites (sites with fewer than 10 randomized participants) sites within a 
geographic region (Canada/USA/Rest of World) with fewer than 10 randomized participants will 
be pooled into a single pooled site for use in efficacy analyses. 
The software used for all summary statistical analyses will be SAS® (SAS Institute, Inc.) version 
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9.3.2 Efficacy Analysis 
The primary and secondary efficacy estimand analyses will be conducted on the intent-to-treat 
(ITT) population, defined as all participants randomized into the trial with grouping by 
randomized treatment, regardless of treatment actually received.   Two additional analyses to the 
primary analysis will be conducted: (1) the primary analysis reapplied to the Per Protocol 
population; (2) a re-randomization analysis to demonstrate that minimization did not bias the 
primary endpoint analysis.  
In order to protect the overall trial false positive rate, the primary efficacy estimand analysis and 
secondary efficacy estimand analyses will be analyzed in a fixed sequence, stopping and calling 
all subsequent analyses exploratory (and accepting the null hypothesis) at the first failed 
hypothesis test in the sequence. The fixed sequential order is: 
1) Primary efficacy estimand analysis. 
2) Secondary efficacy estimand analyses, as specified in the order presented in Table 9-1 
below. 
Table 9-1: Statistical Analysis Methods 
Endpoint 
Statistical Analysis Methods 
Primary 
Overall proportion participants experiencing a favorable functional outcome 
90-days post-randomization, defined as 0 to 2 on the mRS. 
The pivotal primary analysis will be conducted on the ITT population at the 
one-sided 0.025 (2-sided 0.05) significance level overall (for the trial), 
adjusted for the interim analysis per the O’Brien-Fleming boundary spending 
function. It will use the method of Ge et al, 201140. The proportion difference 
in responder rate between two treatment groups and the associated standard 
error and 95% confidence interval will be reported. P-value for the primary 
endpoint will be calculated based on the estimates reported by the Ge et al, 
201140 method. 
The pivotal primary analysis model will be a logistic regression model with 
fixed effects including the treatment group, the stratification covariate of time 
from stroke onset to randomization ≤ 4.5 hours (yes/no) and the randomized 
minimization factors (age, baseline NIHSS score, occlusion location, time 
from qualifying imaging to randomization, baseline ASPECT score, sex, and 
pooled site), and an interaction term of treatment by time from stroke onset to 
randomization. If the interaction term is not significant at the level of 0.05, it 
will be removed from the model. The odds ratios along with the 95% CI will 
be reported in addition to the primary Ge et al, 2011 method results. If the 
interaction term is significant, results will be also reported by randomization 
stratum separately, using the Ge et al, 2011 method. 
A secondary analysis will be conducted in addition to the adjusted primary 
analysis to provide additional insights into the treatment effect (i.e. estimation 
of unadjusted treatment effects). 


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The secondary analysis in support of the primary analysis will be the two 
sample proportion Wald test. The risk difference along with the estimated 
standard error, 95% CI and the Wald test statistics will be reported.  
An additional analysis will be conducted in which the primary analysis is 
reapplied to the per protocol population with observed cases only. 
Three separate efficacy analysis timepoints are planned for this trial. The first 
analysis will be at the interim analysis planned at 60% information on the 
primary endpoint. The second analysis timepoint will be based on the 
completion of Day 90 visits for the main trial. The third analysis will be 
following the completion of the 1-Year follow up. 
Secondary 
The secondary endpoints with binary outcomes (mortality rate, worsening of 
stroke and NIHSS responder) will be assessed via the same analysis as the 
primary analysis (i.e, the logistic regression based, with the odds ratios along 
with the 95% CI and two sample proportion test)  
All tests will be conducted with one-sided significance level of 0.025 (2-sided 
0.05) . A fixed sequence multiple testing procedure will control the overall 
experiment-wise error rate for the trial (see below). It pre-specifies that, with 
all tests conducted at the same pre-specified significance level, the primary 
endpoint will be tested first, and all subsequent tests are considered failed and 
deemed exploratory if conducted, in the order specified (primary analysis first, 
secondary analysis second, etc.), after the first test which fails. The mRS shift 
analysis will only be conducted as part of the fixed sequence testing sequence 
provided that the proportional odds assumption is found to be valid on testing. 
If it is found to be invalid, the remaining secondary endpoints will be deemed 
to analyzed in the fixed testing sequence specified without the mRS shift 
analysis; i.e. it will be removed from the fixed sequence testing sequence. 
Mortality rates, defined as the number of deaths observed divided by the 
number of participants observed over the 90-day study period, will be 
compared between nerinetide and placebo control participants on the ITT set. 
Results will be summarized and tabulated., Mortality analysis will be 
additionally supported using time-to-death survival function analysis, both 
unadjusted shown using Kaplan-Meier analysis and adjusted via Cox 
proportional hazards regression. 
Worsening of Stroke is determined as the number of participants 
experiencing at least one worsening of stroke divided by the number of 
participants observed over the 90-day period in that treatment group, between 
nerinetide and placebo control participants.  Results will be summarized and 
tabulated. 
“mRS shift analysis” The primary analysis of the ordinal mRS scores will 
employ a proportional odds model (POM) to test the hypothesis that, among 
randomized subjects, those who are treated with nerinetide will show a shift in 
their mRS score distribution at 90 days relative to the mRS distribution of the 
placebo subjects. The magnitude of the shift will be estimated as the common 


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odds ratio (95% CI). Modified Rankin scores of 5 and 6 (bed-bound with 
severe disability, and death) will be collapsed into a single category 
representing severely limited functioning. An adjusted POM will be used to 
derive the common odds of improvement (i.e. the nerinetide vs. placebo 
“shift” in mRS score distributions). Adjustment of the treatment effects will 
include the same set of variables as used for the logistic regression model for 
the primary estimand.  Deceased participants will be included with a mRS 
score of 6.   
Since the analysis of the ordinal mRS scores will employ a proportional odds 
model (POM), if test of the proportional odds assumption shows the 
assumption to be invalid, this secondary analysis will be removed from the 
fixed sequence testing procedure and conducted as an exploratory analysis 
instead. 
NIHSS scores at Day 90 will be dichotomized into 0-2 (indicating a good 
neurological outcome) versus >2 (indicating otherwise). Deceased participants 
will be included with a NIHSS score of 42.  The proportion of participants 
achieving a good neurological outcome at Day 90 in nerinetide versus placebo 
control participants will be analyzed. Results will be summarized and 
tabulated.  
Tertiary 
Total volume of new strokes on MRI or CT brain imaging in the nerinetide 
versus placebo control participants.  Total volume will be assessed using an 
unadjusted two-tailed Student’s t-test and supported by an adjusted analysis 
comprising of a linear regression that includes the stratification and 
minimization variables. A cubic root transformation will be performed if 
needed. Results will be reported with confidence intervals for the unadjusted 
and adjusted treatment effect between treatment groups. 
Barthel, Day 90 mRS≤1, Day 90 mRS 4-6, the tertiary outcomes comprising 
proportions of responders will be analyzed similarly to the primary efficacy 
analysis. Deceased participants will be included in the ITT population with a 
Barthel Index score of 0. 
EQ-5D-5L will be assessed descriptively.  Results will be summarized and 
tabulated.   
Exploratory 
Exploratory subgroup analyses will be conducted to determine whether any of 
these factors can modify the effect of the nerinetide vs. placebo treatments. 
Sub-group analyses will be performed on the primary outcome and include 
forest plots to display effect sizes by sub-group6. 
Dichotomous sub-groups of interest include the following:   
• Time from stroke onset to randomization (≤4.5 hours vs. > 4.5 hours)  
• Age (<80 years vs ≥ 80 years of age) 
• Age (<65 years vs ≥ 65 years of age) 
• Sex (men vs. women) 


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• Ethnicity (Hispanics vs non-Hispanic) 
• Race (White, Asian, Black, Other) 
• Baseline stroke severity (NIHSS > Median vs. NIHSS <= Median) 
• Baseline occlusion location (MCA vs. ICA) 
• Baseline ASPECT score (5-7 vs. 8-10) 
• Time from qualifying imaging to study drug initiation (greater than vs. 
less than the median). 
• Time from onset of stroke symptoms to start of study drug (greater than 
vs. less than the median).  
• Degree of reperfusion (TICI 2b-3 vs. TICI <2b) 
• Subjects weighing between 105-120 kg. vs. ≤ 105 kg. 
•  Subjects receiving a thrombolytic treatment post-randomization vs. those 
that do not. 
• Subjects diagnosed with COVID-19 infection while in the acute care 
hospital or known to have active COVID-19 infection at presentation vs. 
those that do not. 
• Subjects who received a thrombolytic as a rescue medication vs. those 
that do not 
• Subjects in whom there was a reported AE of recurrent stroke vs. those 
in who there was not 
Additional sub-groups may be examined. 
Sub-group analysis results will also be reported by randomization strata if the 
interaction term in the primary pivotal analysis plus the treatment-by-
stratification interaction term is significant at the 0.05 level in the adjusted 
logistic regression of the primary analysis. 
9.3.2.1 Adjustment for Covariates  
Adjustment will be conducted as described in Table 9-1. Full details will be specified in detail in 
the SAP. 
9.3.2.2 Outcome Analysis for 1-Year Sub-Study  
The outcomes of the 1-Year Sub-Study are intended to be supportive of the 90-day outcomes of 
the main study. The analysis population will be comprised of participants with a valid consent 
for the 1-year sub-study in the relevant jurisdiction. Missing data will be imputed as per 
Section 9.3.1. A summary table will specify the differences between the population analyzed in 
the main study and the 1-year sub-study, including deaths, losses to follow-up and withdrawal of 
consent. 
The primary outcome is the proportion of subjects with independent functioning on the modified 
Rankin Scale (mRS), as defined by a score of 0-2) at 1 year. 
The secondary outcomes include: 


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• A reduction in mortality rate, as defined by event rate (%) for mortality over the 1-year study 
period. 
• The proportion of subjects with independent function on activities of daily living defined on 
the modified Barthel Index (BI) with a score of ≥ 95 at 1 year. 
• Health-related quality of life, as measured by the EQ-5D-5L at 1 year. 
9.3.3 Analyses of Safety  
All safety analyses will be performed on the Safety Population.  The main analyses will be 
frequency of SAEs and 90-day mortality.   
Endpoint 
Statistical Analysis Methods 
Serious Adverse 
Events 
The frequency of SAEs will be summarized using the Medical Dictionary 
for Regulatory Activities (MedDRA) Version 23.1.  
SAEs leading to 
death 
The frequency of fatal SAEs will be summarized using the Medical 
Dictionary for Regulatory Activities (MedDRA) Version 23.1. 
Adverse Events 
The frequency of AEs will be summarized using the Medical Dictionary for 
Regulatory Activities (MedDRA) Version 23.1. 
Vital Signs 
Absolute values and changes for vital signs from pre-dose to Day 2 will be 
documented. The maximum deviation of BP from Baseline between drug 
and placebo control groups (systolic and diastolic) to Day 2 will be 
analyzed. 
Lab Safety  
Absolute values for laboratory results will be summarized descriptively.    
Prior and 
Concomitant 
Medications 
Prior and concomitant medications will be summarized using the WHO 
Drug Dictionary. 
9.3.4 Pharmacokinetics  
Descriptive statistics will be calculated for plasma concentrations and for all PK parameters 
(nerinetide). In addition, dose proportionality and linearity of dose dependent PK parameters will 
be investigated. Individual and mean plasma concentration versus time curves will be plotted on 
linear and semi-logarithmic scales. Plasma concentration versus time curves will be labelled 
appropriately with treatment regimen and batch number. 
Actual sampling time-points will be recorded and used for PK calculations. If data permit, the 
following PK parameters for nerinetide will be calculated at the end of the study by standard 
noncompartmental methods for all participants with PK samples: 
• AUC0–t: Area under the concentration-time curve from time zero to time of last measurable 
concentration 
• AUC0–inf: Area under the concentration-time curve from time zero to infinity 
• Cmax: Maximum plasma concentration observed after dosing 
• 
Tmax: Time to occurrence of Cmax 


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• t½: Terminal elimination half-life 
Samples with no detectable nerinetide will be excluded from analysis (placebo). 
9.4 
Interim Analysis 
There will be an interim efficacy analysis in this trial. It will be conducted by the unblinded 
statistician in the Independent Statistical Group. 
The interim efficacy analysis will be performed after approximately 510 participants have 
complete the Day 90 follow-up, at 60% information on the primary endpoint. The planned sample 
size is 850 participants randomized 1:1, allowing for a single interim analysis at 60% information 
(when about 510 patients have primary endpoint assessments) with O’Brien-Fleming alpha-
spending function stopping boundary for overwhelming efficacy.     . The cumulative alpha spent 
at the interim analysis is 0.004 and final analysis 0.025, 1-sided; the stopping boundaries on the Z 
scale are 2.668 (interim) and 1.981 (final) and on the p-value scale 0.004 (interim) and 0.021 
(final), all on the assumption that the interim is conducted at 60% information . 
These calculations were performed by taking into account a dropout/non-evaluable rate of 2% 
with 4 month lag to primary endpoint assessment, estimated accrual rate of 50 participants per 
month, target effects 0.5 vs 0.6114 and a single interim analysis for early superiority stopping 
with an O'Brien-Fleming alpha spending function boundary at 60% information (510 evaluable 
participants). [EaST v6.5, 2022].  
The IDMC may recommend stopping for overwhelming efficacy at the interim analysis if the test 
statistic crosses the O-F boundary.  The IDMC Charter will provide further details on the rationale 
for, and how, these recommendations will be communicated.  
 


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10 SUPPORTING DOCUMENTATION and OPERATIONAL CONSIDERATIONS 
10.1 Appendix 1: Regulatory, Ethical, and Study Oversight Considerations 
10.1.1 Regulatory and Ethical Considerations 
This study will be conducted in accordance with the protocol and with the following: 
• Consensus ethical principles derived from international guidelines including the 
Declaration of Helsinki and Council for International Organizations of Medical Sciences 
(CIOMS) International Ethical Guidelines 
• Applicable ICH Good Clinical Practice (GCP) Guidelines 
• Applicable laws and regulations including: Canadian Food and Drug Regulations, and 
the Canadian Tri-Council Policy Statement on Ethical Conduct for Research involving 
Humans (2), United States Code of Federal Regulations (CFR; including Title 21 Parts 
50, 54, 56, and 312), where applicable. 
• Applicable guidelines issued due to the COVID-19 pandemic 
The protocol, protocol amendments, ICF, Investigator Brochure, and other relevant documents 
(e.g., advertisements) must be submitted to an IRB/IEC by the investigator and reviewed and 
approved by the IRB/IEC before the study is initiated. 
Any amendments to the protocol will require IRB/IEC approval before implementation of changes 
made to the study design, except for changes necessary to eliminate an immediate hazard to study 
participants. 
The investigator will be responsible for the following: 
• Providing written summaries of the status of the study to the IRB/IEC annually or more 
frequently in accordance with the requirements, policies, and procedures established by 
the IRB/IEC 
• Notifying the IRB/IEC of SAEs or other significant safety findings as required by 
IRB/IEC procedures 
• Providing oversight of the conduct of the study at the site and adherence to requirements 
of 21 CFR, ICH guidelines, the IRB/IEC, European regulation 536/2014 for clinical 
studies (if applicable), and all other applicable local regulations 
10.1.2 Financial Disclosure 
As requested to allow the sponsor to submit complete and accurate financial certification or 
disclosure statements to the appropriate regulatory authorities, investigators and sub-investigators 
may provide the sponsor with sufficient, accurate financial information. This includes information 
on financial interests during the course of the study and potentially for one year after completion 
of the study. 
Routine care is expected to be paid for by the existing standard medical insurance system.  This 
will include but is not limited to: 


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• Admission to hospital 
• Baseline laboratory testing, pregnancy test, baseline NCCT and CTA, baseline CTP 
• Endovascular procedure and angiography 
• Follow-up limited-sequence MR brain imaging at Day 2/3 
• Follow-up laboratory testing (other than the mandated tests at Day 2/3) 
• Physician fees 
• Treatment processes in the endovascular lab since they are considered standard of care 
• Stroke unit care in hospital 
• Nursing care 
• Rehabilitation and home care if relevant 
• Outpatient clinic follow-up at 90 days (routine) 
The study fees are designed to cover the costs of study personnel, data collection, research study 
processes and treatments, the 30-day follow up visit, the 90-day follow-up visit, 1-Year  follow up 
contact, CRF completion, adverse event reporting, concomitant medication reporting, submission 
of imaging to the core lab and support of remote monitoring, if applicable.  The study fees are 
inclusive of any local institutional overhead/indirect costs. 
10.1.3 
Informed Consent Process 
See Section 5.5.2 for further details. 
10.1.4 Data Protection 
Participants will be assigned a unique identifier by the sponsor. Any participant records or 
datasets that are transferred to the sponsor will contain the identifier only; participant names or 
any information which would make the participant identifiable will not be transferred. 
The participant must be informed that his/her personal study-related data will be used by the 
sponsor in accordance with local data protection law. The level of disclosure must also be 
explained to the participant who will be required to give consent for their data to be used as 
described in the informed consent  
Personal medical information may be reviewed for the purpose of verifying data recorded in the 
eCRF by the site monitors.  Other properly authorized persons, such as the regulatory authorities, 
may also have access to these records.  Personal medical information is always treated as 
confidential.  The participant must be informed that his/her medical records may be examined by 
Clinical Quality Assurance auditors or other authorized personnel appointed by the sponsor, by 
appropriate IRB/IEC members, and by inspectors from regulatory authorities. 
All imaging, evaluation forms, reports, and other records that leave the site are identified only by 
the site and participant number to maintain participant confidentiality.  All records are kept in a 
locked file cabinet. Clinical information is not released without written permission of the 


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participant, except as necessary for monitoring by REB/IRB, Health Canada, the sponsor, or the 
sponsor’s designee. 
All study investigators at the clinical sites, monitors and sponsor staff must ensure that the 
confidentiality of personal identity and all personal medical information of study participants are 
maintained at all times.  Federal legislation in Canada (PIPEDA), U.S (HIPAA), Europe (GDPR) 
and local legislations must be followed. 
10.1.5 Committees Structure 
Safety reviews may be performed several times by the Sponsor’s staff in the course of the trial. 
Any questions pertaining to the reported clinical data will be submitted to the investigator for 
resolution.  Each step of this process will be monitored through the implementation of individual 
passwords to maintain appropriate database access and to ensure database integrity. 
10.1.5.1 Independent Data Monitoring Committee 
The Independent Statistical Group will perform the efficacy interim analysis after approximately 
510 participants complete the Day 90 follow-up.  The interim analysis for efficacy will also be 
assessed by the IDMC which will review unblinded trial safety and efficacy data and make 
recommendations to the blinded Sponsor regarding continuation or stopping. The IDMC may 
recommend the trial be stopped for overwhelming efficacy at the interim analysis if the test 
statistic crosses the O’Brien-Fleming43.  
Activities, mandate, responsibilities, communication structure and function of the IDMC and the 
Independent Statistical Group will be documented in the IDMC Charter prospectively. A Blinding 
Plan will also be included, specifying sequestering and blinding measures planned for the trial 
(including analysis firewalls) to prevent operational bias from revelation outside the IDMC of any 
aggregate interim results on safety or efficacy by treatment arm. 
To prevent operational bias all interim results on safety and efficacy will be reported only to the 
IDMC, keeping the sponsor, project team, investigators and participant blind to results by 
treatment assignment during the study. Firewalls will be in place at the Statistical Analysis Center 
preparing all interim reports to protect and sequester all interim results on safety and efficacy. 
This will be detailed in the IDMC Charter. 
10.1.6 Dissemination of Clinical Study Data 
Study information and tabular study results will be posted on the US National Institutes of 
Health’s website www.clinicaltrials.gov within one year of study completion. 
10.1.7 Data Quality Assurance 
All participant data relating to the study will be recorded on the electronic CRF unless transmitted 
to the sponsor or designee electronically (e.g., imaging). The investigator is responsible for 
verifying that data entries are accurate and correct signing the CRF.  The investigator must 
maintain accurate documentation (source data) that supports the information entered in the CRF. 
The investigator must permit study-related monitoring, audits, IRB/IEC review, and regulatory 
agency inspections and provide direct access to source data documents.  The investigator agrees to 


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allow the monitor(s) direct access to all relevant documents, and to allocate his/her time and the 
time of staff to discuss findings, corrective actions and any relevant issues. In addition to contacts 
during the study, the monitor may also contact the site prior to the start of the study to discuss the 
protocol and data collection procedures with site personnel. 
Except for an emergency situation in which proper care for the protection, safety and well- being 
of the study participants requires medical treatment, the study will be conducted as described in 
the approved protocol, ICH-GCP, SOPs and regulatory requirements.  All medical treatments will 
be recorded.  Any deviation(s) from the protocol will be recorded and presented in the final 
clinical study report. 
To ensure monitoring responsibilities are performed to the fullest extent possible, industry 
experienced study monitors will perform on site data verification for the trial.  All data monitored 
on site are verified for accuracy and completeness using source documents for all participants. 
The sponsor will determine the extent, nature, and frequency of on-site visits that are needed to 
ensure that the study is being conducted in accordance with the approved protocol (and any 
amendments), GCP, and all applicable regulatory requirements  Monitoring details describing 
strategy (e.g., risk-based initiatives in operations and quality such as Risk Management and 
Mitigation Strategies and Analytical Risk-Based Monitoring), methods, responsibilities and 
requirements, including handling of noncompliance issues and monitoring techniques (central, 
remote, or on-site monitoring) are provided in the Monitoring Plan. 
The sponsor or designee is responsible for the data management of this study including quality 
checking of the data.  The sponsor assumes accountability for actions delegated to other 
individuals (e.g., Contract Research Organizations). 
Study monitors will perform ongoing source data verification to confirm that data entered into the 
CRF by authorized site personnel are accurate, complete, and verifiable from source documents; 
that the safety and rights of participants are being protected; and that the study is being conducted 
in accordance with the currently approved protocol and any other study agreements, ICH GCP, 
and all applicable regulatory requirements.  This review may occur at the study site or remotely.  
Any records supplied by the site for the purpose of remote monitoring and remote source 
document verification must comply with local legislation and the process approved by the local 
IRB/EC/REB, when required. 
Records and documents, including signed ICFs, pertaining to the conduct of this study must be 
retained by the investigator for 15 years after study completion unless local regulations or 
institutional policies require a longer retention period. No records may be destroyed during the 
retention period without the written approval of the sponsor. No records may be transferred to 
another location or party without written notification to the sponsor. 
10.1.8 Source Documents 
Source documents provide evidence for the existence of the participant and substantiate the 
integrity of the data collected. Source documents are filed at the investigator’s site.  Source 
documents specification per site will be agreed prior to first participant enrolled at the site. 
Data reported in the eCRFs must be consistent with the source documents or the discrepancies 
must be explained. The investigator may need to request previous medical records or transfer 


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records, depending on the study. Also, current medical records must be available.  Any records 
supplied by the site for the purpose of remote monitoring and remote source document 
verification must be de-identified using only the unique trial specific participant identifier.  This 
process will be aligned with local ethics and privacy requirements.  
If clinical outcome assessments are collected using the electronic Clinical Outcome Assessment 
(eCOA) tool data will transferred directly to the eCRF, in this case the eCOA record will be the 
sole source document for these assessments. 
Any investigators shall supply the sponsor, upon request, with any required background data from 
the study documentation or clinic records. This is particularly important when errors in data 
transcription are suspected.  In case of special problems and/or governmental queries or requests 
for audit inspections, it is also necessary to have access to the complete study records, provided 
that participant confidentiality is protected. 
Definition of what constitutes source data may include: participant hospital/clinic records, 
physician's and nurse's notes, appointment book, original laboratory reports, ECG, X-ray, 
pathology and special assessment reports, signed consent forms, consultant letters, and source 
worksheets.  
The Investigator must maintain adequate and accurate records to enable the conduct of the study 
to be fully documented and the study data to be subsequently verified. These documents should be 
classified into two different separate categories: (1) Investigator's Study File; and (2) Participant 
Clinical Source Documents. 
The Investigator's Study File will contain the Protocol/Amendments, CRFs, REB/IRB and 
governmental approval with correspondence, all versions of ethics approved informed consent 
forms, staff curriculum vitae and authorization forms and other appropriate 
documents/correspondence, etc. 
The investigator must keep these two categories of documents on file according to local clinical 
trial regulation.  In Canada, all study documents for a regulated trial require storage for 15 years. 
After that period of time the documents may be destroyed, participant to local regulations.  
The Investigator and the sponsor will maintain the records of disposition of the drug and the clinic 
records in accordance with ICH-GCP and each applicable regulatory agency.  Clinic records will 
be retained at the site until informed by the sponsor to destroy the documents.  If the clinical study 
must be terminated for any reason, the investigator will return all study materials to the sponsor 
and provide a written statement as to why the termination has taken place and notify the REB/IRB 
10.1.9 Study and Site Start and Closure 
The study start date is the date on which the clinical study will be open for recruitment of 
participants.  The first act of recruitment is the first site open and will be the study start date. 
The sponsor designee reserves the right to close the study site or terminate the study at any time 
for any reason at the sole discretion of the sponsor, which may include new or emerging safety 
information that negatively affects the benefit/risk profile of the drug.  


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Study sites will be closed upon study completion at 1-Year. A study site is considered closed 
when all required documents and study supplies have been collected and a study-site closure visit 
has been performed. 
The investigator may initiate study-site closure at any time, provided there is reasonable cause and 
sufficient notice is given in advance of the intended termination. 
Reasons for the early closure of a study site by the sponsor or investigator may include but are not 
limited to: 
• 
Failure of the investigator to comply with the protocol, the requirements of the REB/IRB 
or local health authorities, the sponsor's procedures, or GCP guidelines 
• 
Inadequate recruitment of participants by the investigator 
• 
Discontinuation of further study intervention development 
If the study is prematurely terminated or suspended, the sponsor shall promptly inform the 
Investigators, the REBs/IRBs, the regulatory authorities, and any contract research organization(s) 
used in the study of the reason for termination or suspension, as specified by the applicable 
regulatory requirements. The Investigator shall promptly inform the participant and should assure 
appropriate participant therapy and/or follow-up 
10.1.10 Publication Policy 
The results of this study may be published or presented at scientific meetings. If this is foreseen, 
the investigator agrees to submit all manuscripts or abstracts to the sponsor before submission. 
This allows the sponsor to protect proprietary information and to provide comments. 
The sponsor will permit any and all academic publications arising from the trial data provided that 
no publication containing unblinded trial data precedes publication of the overall trial results in a 
peer-review journal, and are (1) approved by the trial executive committee and (2) the publication 
authors notify the sponsor at least 30 days prior to submittal for publication with a copy of such 
proposed publication for the sponsor’s review and comment. Employees or consultants of the 
sponsor will only be named as authors in any such publication if the parties agree that it is 
appropriate under the usual conventions used by academic institutions for naming authors in 
scientific publications.  Upon request of the sponsor the publication or disclosure shall be delayed 
for up to 60 days in order to allow for the filing of a patent application. 
The sponsor will comply with the requirements for publication of study results. In accordance 
with standard editorial and ethical practice, the sponsor will generally support publication of 
multicentre studies only in their entirety and not as individual site data. In this case, a coordinating 
investigator will be designated by mutual agreement. 
A trial executive committee shall be formed and include at least the trial principal investigator and 
co-principal investigator, the statistical consultant, and representatives of the Sponsor.  The trial 
executive committee will be co-authors on all publications and presentations.  The primary author 
list for the primary publication will consist of the executive committee and the site 
principal/qualified investigator at each of the sites.  A formal publication policy will be presented 
and developed by the trial executive. 


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Authorship will be determined by mutual agreement and in line with International Committee of 
Medical Journal Editors authorship requirements. 
10.1.11Audits and Inspections 
In accordance with the principles of ICH E6 Guideline for Good Clinical Practice, the study site 
may be inspected by regulatory authorities and/or audited by NoNO Inc. Quality Assurance 
(QA) or their designates. The investigator and relevant clinical support staff will be required to be 
actively involved in audits and inspections, including staff interviews, and to make all necessary 
documentation and data available upon request. 
During the course of the study and/or after it has been completed, one or more investigator site 
audits may be undertaken by auditors from NoNO QA or delegates. The purpose of these audits is 
to determine whether or not the study is being/has been conducted and monitored in compliance with 
recognized ICH E6 Guideline for Good Clinical Practice, protocol and approved amendment 
requirements, applicable local SOPs, and local laws and regulations. It is the responsibility of the 
investigator and site staff to promptly address, by coordinating with NoNO Inc. any deficiencies 
stemming out of regulatory inspections and NoNO QA or delegate audits, and to ensure that 
agreed-upon corrective and preventive actions are implemented as soon as possible. 
An inspection by any regulatory authority may occur at any time during or after completion of the 
study. If an investigator is contacted by a regulatory authority for the purpose of conducting an 
inspection or to discuss any compliance issues, he/she is required to contact NoNO Inc 
immediately. 
 
 


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10.2 Appendix 2: Clinical Laboratory Tests and Imaging  
10.2.1 Clinical Laboratory Tests 
The tests detailed in Table 10-1 will be performed as per local hospital laboratory. 
Table 10-1: Protocol-Required Safety Laboratory Assessments 
Laboratory Tests 
Parameters 
Hematology 
Platelet Count 
Hemoglobin 
Hematocrit 
Chemistry 
Serum creatinine 
Serum glucose 
Electrolytes 
Sodium 
Potassium 
Chloride 
Pregnancy testing 
Highly sensitive (Serum or urine) human chorionic gonadotropin (hCG) pregnancy test (as 
needed for women of childbearing potential) 
 
10.2.2 Imaging 
At baseline all participants will undergo brain imaging for assessment of inclusion into the trial as 
described in Section 5.5.1.  The Day 2/3 MR will be used to assess infarct volume (including a 
minimum of axial DWI, gradient-echo (GRE), FLAIR).  The Day 2/3 MR is considered a standard 
of care imaging procedure.  If MR is unavailable, then NCCT is allowed. 
The baseline and all brain/neurovascular imaging conducted up to the Day 2/3 MR will be 
rendered anonymous and sent to the central core imaging lab.  The core imaging lab staff will 
review the imaging against the imaging inclusion/exclusion criteria found in Sections 5.1 and 
5.2in order to ensure adherence to the imaging guidelines and enrollment criteria for training 
purposes.  Centrally adjudicated imaging will be used to determine baseline ASPECT scores, 
adherence to qualifying imaging criteria, as well as, reperfusion rates (TICI scores) and volume of 
stroke at Day 2/3.  Other brain imaging will be sent only if requested by the adjudication 
committee. 
For all interval times assessed from imaging, the time zero will be the first slice of the NCCT scan.  
Imaging date and time will be collected in the CRF. 
Notes:  
Sites that did not participate in the ESCAPE-NA1 trial will submit sample images to the 
imaging core lab for quality assessment.   
Baseline imaging may be completed at a hospital affiliated with the trial site. 
 
 


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10.3 Appendix 3: Adverse Events: Definitions and Procedures for Recording, Evaluating, 
Follow-up, and Reporting 
10.3.1 Definition of AE 
AE Definition 
An AE is any untoward medical occurrence in a patient or clinical investigation participant 
administered a pharmaceutical product and which does not necessarily have to have a causal 
relationship with this treatment.  
An AE can therefore be any unfavorable and unintended sign (including an abnormal 
laboratory finding, for example), symptom or disease temporally associated with the use of 
a medicinal product, whether or not considered related to the medicinal product.  
Adverse Drug Reaction (ADR)  
In the pre-approval clinical experience with a new medicinal product or its new usages, 
particularly as the therapeutic dose(s) may not be established: all noxious and unintended 
responses to a medicinal product related to any dose should be considered adverse drug 
reactions.  The phrase "responses to a medicinal product" means that a causal relationship 
between a medicinal product and an adverse event is at least a reasonable possibility, i.e., the 
relationship cannot be ruled out. 
Unexpected Adverse Drug Reaction  
An adverse reaction, the nature or severity of which is not consistent with the applicable 
product information (e.g., Investigator's Brochure for an unapproved investigational 
medicinal product). 
Events Meeting the AE Definition 
• A new illness 
• The worsening of a concomitant illness 
• Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) or 
other safety assessments (e.g., ECG, radiological scans, vital signs measurements), 
including those that worsen from baseline, considered clinically significant in the medical 
and scientific judgment of the investigator (i.e., not related to progression of underlying 
disease). 
• Exacerbation of a chronic or intermittent pre-existing condition including either an 
increase in frequency and/or intensity of the condition. 
• New conditions detected or diagnosed after study intervention administration even though 
it may have been present before the start of the study. 
• Signs, symptoms, or the clinical sequelae of a suspected drug-drug interaction. 
• Signs, symptoms, or the clinical sequelae of a suspected overdose of either study 
intervention or a concomitant medication. Overdose per se will not be reported as an 
AE/SAE unless it is an intentional overdose taken with possible suicidal/self-harming 
intent. Such overdoses should be reported regardless of sequelae. 


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10.3.2 Definition of SAE 
A SAE is defined as any untoward medical occurrence that, at any dose: 
a. Results in death 
All deaths occurring during the follow up to Day 90 will be reported as an SAE.  When reporting 
a death, the event or condition that caused or contributed to the fatal outcome should be reported 
as a single medical concept. 
b. Is life-threatening 
The term 'life-threatening' in the definition of 'serious' refers to an event in which the participant 
was at risk of death at the time of the event. It does not refer to an event, which hypothetically 
might have caused death, if it were more severe. 
c. Requires inpatient hospitalization or prolongation of existing hospitalization 
• In general, hospitalization signifies that the participant has been detained (usually 
involving at least an overnight stay) at the hospital or emergency ward for observation 
and/or treatment that would not have been appropriate in the physician’s office or 
outpatient setting. Complications that occur during hospitalization are AEs. If a 
complication prolongs hospitalization or fulfills any other serious criteria, the event is 
serious. When in doubt as to whether “hospitalization” occurred or was necessary, the AE 
should be considered serious. 
• Hospitalization for elective treatment of a pre-existing condition that did not worsen from 
baseline is not considered an AE. 
d. Results in persistent disability/incapacity 
• The term disability means a substantial disruption of a person’s ability to conduct normal 
life functions. 
• This definition is not intended to include experiences of relatively minor medical 
significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, and 
accidental trauma (e.g., sprained ankle) which may interfere with or prevent everyday life 
functions but do not constitute a substantial disruption. 
e. Is a congenital anomaly/birth defect 
f. Other situations: a SAE can also be an important medical event that may not result in death, 
be life-threatening, or require hospitalization, but may jeopardize the participant and may 
require medical or surgical intervention to prevent one of the outcomes listed in this 
definition: 
• Medical or scientific judgment should be exercised in deciding whether SAE reporting is 
appropriate in other situations such as important medical events that may not be 
immediately life-threatening or result in death or hospitalization but may jeopardize the 
participant or may require medical or surgical intervention to prevent one of the other 


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outcomes listed in the above definition. These events should usually be considered 
serious. 
• 
Examples of such events include invasive or malignant cancers, intensive treatment in an 
emergency room or at home for allergic bronchospasm, blood dyscrasias or convulsions 
that do not result in hospitalization, or development of drug dependency or drug abuse. 
10.3.3 Recording and Follow-Up of AE and/or SAE 
AE and SAE Recording 
• When an AE/SAE occurs, it is the responsibility of the investigator to review all 
documentation (e.g., hospital progress notes, laboratory reports, and diagnostics reports) 
related to the event. 
• The investigator will then record all relevant AE/SAE information in the CRF. 
• It is not acceptable for the investigator to send photocopies of the participant’s medical 
records to the Sponsor in lieu of completion of the CRF pages and SAE reports. 
• There may be instances when copies of medical records for certain cases are requested by 
the Sponsor. In this case, all participant identifiers, with the exception of the participant 
study identification number, will be redacted on the copies of the medical records before 
submission to the Sponsor. 
• The investigator will attempt to establish a diagnosis of the event based on signs, 
symptoms, and/or other clinical information. Whenever possible, the diagnosis (not the 
individual signs/symptoms) will be documented as the AE/SAE. 
Assessment of Intensity 
The investigator will make an assessment of intensity for each AE and SAE reported during the 
study and assign it to 1 of the following categories:  
• Mild: Awareness of sign or symptom but easily tolerated. 
• Moderate: Discomfort sufficient to cause interference with normal activities. 
• Severe: Incapacitating, with inability to perform normal activities.   
An AE that is assessed as severe should not be confused with a SAE. Severe is a category utilized 
for rating the intensity of an event; and both AEs and SAEs can be assessed as severe.  An event 
is defined as ‘serious’ when it meets at least 1 of the predefined outcomes as described in the 
definition of an SAE, NOT when it is rated as severe. 
Assessment of Causality 
• The investigator is obligated to assess the relationship between study intervention and 
each occurrence of each AE/SAE. 
• A “reasonable possibility” of a relationship conveys that there are facts, evidence, and/or 
arguments to suggest a causal relationship, rather than a relationship cannot be ruled out. 


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• The investigator will use clinical judgment to determine the relationship. 
• Alternative causes, such as underlying disease(s), concomitant therapy, and other risk 
factors, as well as the temporal relationship of the event to study intervention 
administration will be considered and investigated. 
• The investigator will also consult the Investigator’s Brochure (IB) and/or Product 
Information, for marketed products, in his/her assessment. 
• For each AE/SAE, the investigator must document in the medical notes that he/she has 
reviewed the AE/SAE and has provided an assessment of causality. 
• There may be situations in which an SAE has occurred and the investigator has minimal 
information to include in the initial report to the Sponsor. However, it is very important 
that the investigator always make an assessment of causality for every event before the 
initial transmission of the SAE data to the Sponsor. 
• The investigator may change his/her opinion of causality in light of follow-up information 
and send a SAE follow-up report with the updated causality assessment. 
• The causality assessment is one of the criteria used when determining regulatory reporting 
requirements. 
AE Causality/ Relationship 
Related 
A clinical event, including laboratory test abnormality, where there is a 
“reasonable possibility” that the SAE was caused by the study drug, meaning that 
there is evidence or arguments to suggest a causal relationship. 
Possibly: 
A clinical event, including laboratory test abnormality, with a reasonable time 
sequence to drug administration, but which could also be explained by concurrent 
disease or other drugs or chemicals.  Information on drug withdrawal may be 
lacking or unclear. 
Unrelated: This category is applicable to AEs which are judged to be clearly and 
incontrovertibly due to extraneous causes (diseases, environment, etc.) and do not 
meet the criteria for drug relationship listed for the above-mentioned conditions. 
Follow-up of AEs and SAEs 
• The investigator is obligated to perform or arrange for the conduct of supplemental 
measurements and/or evaluations as medically indicated or as requested by the Sponsor 
to elucidate the nature and/or causality of the AE or SAE as fully as possible. This may 
include additional laboratory tests or investigations, histopathological examinations, or 
consultation with other health care professionals. 
• If a participant dies during participation in the study the investigator may be requested by 
the Sponsor to provide the Sponsor with a copy of any post-mortem findings including 
histopathology. 
• New or updated information will be recorded in the originally completed CRF. 


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• The investigator will submit any updated SAE data to the Sponsor within 24 hours of 
receipt of the information. 
 
10.3.4 Reporting of SAEs 
SAE Reporting to the Sponsor via an Electronic Data Collection Tool 
• The primary mechanism for reporting an SAE to the Sponsor will be the electronic data 
collection tool. 
• If the electronic system is unavailable, then the site will use the paper SAE data collection 
tool (see next section) in order to report the event within 24 hours. 
• The site will enter the SAE data into the electronic system as soon as it becomes available. 
• After the study is completed at a given site, the electronic data collection tool will be taken 
off-line to prevent the entry of new data or changes to existing data. 
• If a site receives a report of a new SAE from a study participant or receives updated data 
on a previously reported SAE after the electronic data collection tool has been taken off-
line, then the site can report this information on a paper SAE form or to the Drug Safety 
Department at NoNO by telephone or email. 
 
1-416-583-1687 or sae@nonoinc.ca 
SAE Reporting to the Sponsor via Paper CRF 
If the eCRF system is not available, a paper SAE form should be directed within 24 hours to:  
Drug Safety at NoNO Inc. 
sae@nonoinc.ca or  
1-416-583-1856 (for fax) 
Initial notification via telephone does not replace the need for the investigator to complete and 
sign the SAE CRF pages within the designated reporting time frames. 
 
 
 


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10.4 Appendix 4: Collection of Pregnancy Information 
Male participants with partners who become pregnant 
The investigator will attempt to collect pregnancy information on any male participant’s female 
partner who becomes pregnant while the male participant is in this study. This applies only to 
male participants who receive study drug. 
After obtaining the necessary signed informed consent from the pregnant female partner directly, 
the investigator will record pregnancy information on the Pregnancy Reporting Form and submit 
it to the sponsor within 24 hours of learning of the partner’s pregnancy. The female partner will 
also be followed to determine the outcome of the pregnancy. Information on the status of the 
mother and child will be forwarded to the sponsor. Generally, the follow-up will be no longer than 
4 weeks following the estimated delivery date. Any termination of the pregnancy will be reported 
regardless of fetal status (presence or absence of anomalies) or indication for the procedure.  
Female Participants who become pregnant 
The investigator will collect pregnancy information on any female participant who becomes 
pregnant while participating in this study.  The initial information will be recorded on the 
Pregnancy Reporting Form and submitted to the sponsor within 24 hours of learning of a 
participant’s pregnancy.  
The participant will be followed to determine the outcome of the pregnancy. The investigator will 
collect follow-up information on the participant and the neonate and the information will be 
forwarded to the sponsor. Generally, follow-up will not be required for longer than 4 weeks 
beyond the estimated delivery date. Any termination of pregnancy will be reported, regardless of 
fetal status (presence or absence of anomalies) or indication for the procedure. 
While pregnancy itself is not considered to be an AE or SAE, any pregnancy complication or 
elective termination of a pregnancy for medical reasons will be reported as an AE or SAE. 
A spontaneous abortion (occurring at <22 weeks gestational age) or still birth (occurring at >22 
weeks gestational age) is always considered to be an SAE and will be reported as such. 
Any post-study pregnancy related SAE considered reasonably related to the study intervention by 
the investigator will be reported to the sponsor as described in Section 8.3.4. While the 
investigator is not obligated to actively seek this information in former study participants, he or 
she may learn of an SAE through spontaneous reporting. 
Any female participant who becomes pregnant while participating in the study will discontinue 
study intervention but will continue to be followed to the end of the trial. 
 
 


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10.5 Appendix 5: Abbreviations 
AHA 
American Heart Association  
AIS 
Acute Ischemic Stroke 
AE 
Adverse Event 
AESI 
Adverse Event of Special Interest 
ASPECTS 
Alberta Stroke Program Early Computerized Tomography Score 
β-hCG 
Beta-human Chorionic Gonadotropin 
BI 
Barthel Index 
BP 
Blood Pressure 
CBC 
Complete Blood Count 
CFR 
Code of Federal Regulations 
CI 
Confidence Interval 
CIOMS 
Council for International Organizations of Medical Sciences 
CRA 
Clinical Research Associate  
CRF 
Case Report Form 
CT 
Computed Tomography 
CTA 
Computed Tomographic Angiography 
CTP 
Computed Tomographic Perfusion 
DWI 
Diffusion Weighted Imaging 
EC 
Ethics Committee 
eCOA 
eCRF 
Electronic Clinical Outcome Assessment 
Electronic Case Report Form 
eMCAO 
Embolic Middle Cerebral Artery Occlusion 
ESCAPE-NEXT 
Extension of Stroke Care with Adjuvant neuroProtection to Endovascular 
treatment with Nerinetide EXcluding Thrombolysis 
EQ-5D-5L 
EuroQol health-related quality of life 
EVT 
Endovascular Thrombectomy  
FDA 
Food and Drug Administration 
FLAIR 
Fluid Attenuated Inversion Recovery 
GCP 
Good Clinical Practice 
GDPR 
General Data Protection Regulation 
HIPAA 
Health Insurance Portability and Accountability Act 
HR 
Heart Rate 
ICA 
Internal Carotid Artery  
ICF 
Informed Consent Form 
ICH-GCP 
International Conference on Harmonization-Good Clinical Practice 
IDMC 
Independent Data Monitoring Committee 
IRB 
Institutional Review Board 
ITT 
Intent-to-treat 
IV 
Intravenous 
IWRS 
Interactive Web Response System 
LAR 
Legally Authorized Representative  
LVO 
Large Vessel Occlusion 
MAP 
Mean Arterial Pressure 


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MCA 
Middle Cerebral Artery  
MCAO 
Middle Cerebral Artery Occlusion 
mCTA 
Multiphase Computed Tomography Angiography  
MedDRA 
Medical Dictionary for Regulatory Activities 
MR 
Magnetic Resonance 
MRI 
Magnetic Resonance Imaging 
mRS 
Modified Rankin Scale 
n 
Number of Observations 
NaCl 
Sodium Chloride 
NCCT 
Non-contrast Computed Tomography Scan 
NIHSS 
National Institutes of Health Stroke Scale 
NMDA 
N-methyl D-aspartate 
NMDAR 
N-methyl D-aspartate Receptor 
nNOS 
Neuronal Nitric Oxide Synthase 
NO 
Nitric Oxide 
O-F 
O’Brien Fleming 
pH 
Potential Hydrogen 
PI 
Principal Investigator 
PIPEDA 
Personal Information and Portable Electronic Documents Act 
PK 
Pharmacokinetic 
POM 
Proportional Odds Method 
PP 
Per Protocol 
PSD-95 
Post-synaptic Density 95 Protein 
QA 
Quality Assurance 
REB 
Research Ethics Board 
RR 
Risk Ratio 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SD 
Standard Deviation 
SOC 
System Organ Class 
SOP 
Standard Operating Procedures 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TICI 
Thrombolysis in Cerebral Infarction Score 
tMCAO 
Temporary Middle Cerebral Artery Occlusion 
USA/US 
United States of America 
VAS 
Visual Analogue Scale 
WHO 
World Health Organization 
 
 


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10.6 Appendix 6: Country-specific Requirements 
10.6.1 Addition to Consent Process- Section 5.5.2 
The first option for obtaining consent will be signed informed consent from the participant or 
LAR prior to any protocol-specific procedures.  In accordance with ICH GCP, in a life-
threatening situation, in the event where informed consent is not feasible, the decision to enroll a 
subject may be made by the investigator after consultation with an independent physician who is 
not otherwise participating in the trial provided that it is allowed by applicable national laws and 
regulations and an approved/favourable opinion by the applicable Research Ethics Board/Ethics 
Committee. Any decision made will have considered the patient’s presumed will. 
All methods of conducting the informed consent process must comply with ICH GCP E6.  
Approval for all method(s) of obtaining informed consent as well as the forms used must be 
obtained prior to implementation. 
In the event the subject remains incapacitated, consent to continue participation in the trial should 
be obtained from the LAR as soon as it is possible and reasonable.   
 
10.6.2 Addition to Remote Source Document Verification - Section 10.1.7 
Remote source data verification (rSDV) will only occur at study sites where the country 
regulations allow and prior approval has been granted by the regulatory authority, as 
applicable.   In Germany, rSDV will not occur at study sites.  
 
 


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37. 
Quinn TJ, Langhorne P, Stott DJ. Barthel index for stroke trials: Development, 
properties, and application. Stroke; a journal of cerebral circulation. 2011;42:1146-
1151 
38. 
Brooks R. Euroqol: The current state of play. Health Policy. 1996;37:53-72 
39. 
Herdman M, Gudex C, Lloyd A, Janssen M, Kind P, Parkin D, et al. Development and 
preliminary testing of the new five-level version of eq-5d (eq-5d-5l). Qual Life Res. 
2011;20:1727-1736 
40. 
Ge M DL, and DR Meyer. Covariate-adjusted difference in proportions from clinical 
trials using logistic regression and weighted risk differences. Drug Information 
Journal. 2011;45(4)::481-493 
41. 
Adjusting for covariates in randomized clinical trials for drugs and biological 
products - fda draft guidance for industry. 2021 
42. 
ICH. Ich e9(r1) addendum on estimands and sensitivity analysis in clinical trials to 
the guideline on statistical principles for clinical trials. 2019 
43. 
O'Brien PC, Fleming TR. A multiple testing procedure for clinical trials. Biometrics. 
1979;35:549-556 
 
 


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12 INVESTIGATOR’S AGREEMENT 
 
I have read the attached protocol: A Multicentre, Randomized, Double-blinded, Placebo-
controlled, Parallel Group, Single-dose Design to Determine the Efficacy and Safety of 
Nerinetide in Participants with Acute Ischemic Stroke Undergoing Endovascular 
Thrombectomy Excluding Thrombolysis (ESCAPE-NEXT Trial) (Version number in the 
header above) and agree to abide by all provisions set forth therein. 
 
I agree to comply with the current International Conference on Harmonisation Guidelines for 
Good Clinical Practice and the laws, rules, regulations and guidelines of the community, country, 
state or locality relating to the conduct of the clinical study. 
I also agree that persons debarred from conducting or working on clinical studies by any court or 
regulatory agency will not be allowed to conduct or work on studies for the sponsor. 
 
 
 
 
Name Site Principal Investigator 
 
Signature 
 
 
 
Name of Clinical Site 
 
Date 
 
 
 


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13 ADDENDUM 
13.1 COVID-19 Considerations 
Improving Access to Stroke Care due to Changes in COVID-19  
Based on the clinical data available for nerinetide to date, treatment with nerinetide may slow the 
progression of ischemic brain damage, providing more time during which endovascular 
thrombectomy may be of benefit to the patient. This is of even greater relevance during the global 
COVID-19 pandemic for the following reasons: 
(a) There is a necessity to protect hospital staff, resulting in additional hospital protocols 
involving sanitations and personal protective equipment that minimize the exposure of the 
clinical stroke team to a potentially COVID-19 positive stroke patient (there is no time for 
COVID-19 testing to be completed). 
(b)  There is a necessity to protect the patient, resulting in additional hospital protocols 
involving distancing him/her from hospital staff and sanitizing equipment (e.g., CT 
scanner) used on other patients. 
These necessities slow down emergency stroke care workflows, potentially causing undue delays 
in the emergency stroke care of all AIS patients, not just those who may have been exposed to 
COVID-19. Thus, the possibility that nerinetide, by slowing the progression of ischemic brain 
damage, mitigates such delays may be of direct benefit to treated patients. 
Minimizing Risk to Participants and Staff  
The protocol includes the following adaptations to minimize risk while prioritizing the overall 
well-being and best interests of all involved in the trial.  This protocol was written considering the 
impact of COVID-19 on trial participants, site staff and sponsor staff. With these priorities in 
mind, the protocol design will still permit assessment of safety and efficacy of nerinetide. 
• Minimize the number of study visits to align with the trial endpoints  
• Minimize the number of trial specific activities.  The trial was designed to align with 
standard of care protocols for acute stroke.  For example, obtaining data from standard of 
care assessments conducted during routine stroke care, for the collection and reporting of 
some safety outcomes (vital signs, laboratory results) and imaging outcomes. 
• Conduct visits by telemedicine or by telephone at Day 30 and Day 90, where permitted, 
when a participant is unable to attend the site physically.  This will permit the timely 
collection of efficacy endpoints (mRS, NIHSS, Barthel Index and EQ-5D-5L) and safety 
data (AE and SAE collection).  If the contact is made by phone, only the NIHSS 
assessment will not be completed, all other assessments will be obtained.  
• Use of remote electronic consent, where permitted, to obtain initial consent from the 
LAR, who may not be able to enter the hospital, and to obtain regained capacity consent 
from participants who did not consent prior to their discharge from hospital. 
• Use of electronic Clinical Outcome Assessments (COA) is optional for the conduct of 
the mRS, NIHSS, Barthel Index and EQ-5D-5L assessments at Day 30, Day 90 and 1-Year 
timepoints.  If an electronic COA is used, this will permit site staff to collect trial 


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endpoints even if they are not permitted into the hospital, reduce data entry time and 
reduce the time on-site for CRAs in order to monitor the data. 
In addition to the above items included in the protocol, ongoing risk assessments and monitoring 
of the COVID-19 situation will be conducted by the sponsor with input from the local 
investigators at both a site and country level. These ongoing assessments include changes to any 
of the following: 
• Potential impact on trial participants 
• Potential impact on trial site staff, including local or central REB/IRBs/ECs 
• Potential impact on sponsor/CRO staff conducting site monitoring and central review of 
data. 
The outcome of these ongoing assessments could result in site-specific or country-specific 
mitigation plans, which could include: 
• Suspension of enrollment in that site or country 
• Suspension of on-site visits by participants in that site or country, replacing the physical 
data capture with some remote measures (telephone or telemedicine, where permitted) 
• Suspension of on-site visits being conducted by the CRA, replacing the monitoring with 
remote review of data and telephone contacts with the site 
• Other mitigation plans, as appropriate. 
 
 
 


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13.2 Assessment Questionnaires 
Below is a sample of the assessment questionnaires and instructions to be used in the trial. 
Modified Rankin Scale (mRS) 
Clinician Reported Outcome 
English example  
National Institute of Health Stroke Score 
(NIHSS) 
Clinician Reported Outcome 
English example.   
Barthel Index 
Clinician Reported Outcome 
English example.   
EQ-5D-5L 
Patient Reported Outcome  
USA, English Interviewer Administered example  
See https://euroqol.org/ for device, country, and 
language specific versions 
 


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1 
Statistical Analysis Plan 
A Multicentre, Randomized, Double-blinded, Placebo-controlled, Parallel Group, Single-dose 
Design to Determine the Efficacy and Safety of Nerinetide in Subjects with Acute Ischemic 
Stroke Undergoing Endovascular Thrombectomy Excluding Thrombolysis  
(ESCAPE-NEXT Trial) 
Protocol NA-1-009 
Product:
Nerinetide
IND:
118,087 
Sponsor:
NoNO Inc. 
Date 
18 November 2021 
Version 
Final 2.0 
479A Wellington Street West
Toronto, Ontario, Canada M5V 1E7


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SIGNATURES OF APPROVAL 
Personal Protected Data


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Version History 
This Statistical Analysis Plan (SAP) for the trial ESCAPE-NEXT is based on Protocol V5.0, 
dated  18 November 2021.  
Version Date Change 
Rationale 
1.0 
03 
May 
2021 
Not Applicable 
Original version 
2.0 
18 
Nov 
2021 
- Updated hierarchical testing 
order of secondary endpoints: 
moved the NIHSS responder 
endpoint to the last. 
- The change in testing order of 
NIHSS endpoint was due to the 
concern of increased missingness of 
Day 90 NIHSS scores that may 
impact statistical power.   
- NIHSS cannot be conducted over the 
phone.  Due to COVID-19 there is an 
increase in the number of Day 90 
visits being conducted by phone. 
- Updated the primary analysis 
model for all binary efficacy 
endpoints: a generalized linear 
regression model with 
adjustment for baseline 
covariates and randomization 
stratification factor will be used 
- Changed one of supportive 
analyses of the primary efficacy 
endpoint to an unadjusted 
logistic regression  
- Added robust estimation of 
unconditional treatment effect 
for the primary efficacy endpoint 
analysis 
- The updates in primary analysis 
model as well as the addition of 
unconditional treatment effect were 
made to be aligned with the FDA 
draft guidance “Adjusting for 
Covariates in Randomized Clinical 
Trials for Drugs and Biological 
Products” dated in May 2021 
 
 
 


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TABLE OF CONTENTS 
SIGNATURES OF APPROVAL ................................................................................................... 2 
Version History ............................................................................................................................... 3 
Table of Contents ............................................................................................................................ 4 
List of Tables .................................................................................................................................. 6 
 
Introduction ............................................................................................................................. 7 
1.1 Background .......................................................................................................................... 7 
1.2 Trial Objectives ................................................................................................................... 8 
1.2.1 Primary Objective ....................................................................................................... 8 
1.2.2 Secondary Objectives .................................................................................................. 8 
1.2.3 Tertiary Objectives ...................................................................................................... 8 
1.2.4 Safety Objectives ........................................................................................................ 9 
1.2.5 1- Year Follow Up Analytic Sub-Trial Objectives ..................................................... 9 
1.3 Study Design ...................................................................................................................... 11 
1.4 Sample Size Determination ............................................................................................... 11 
1.5 Randomization ................................................................................................................... 12 
1.6 Blinding of Main Study ..................................................................................................... 14 
1.7 Blinding of 1-year Follow-up Study .................................................................................. 15 
1.7.1 Subjects having the 1-year Follow-up While the Main Study is Blinded ................. 15 
1.7.2 Subjects having the 1-year Follow-up After the Main Study is Unblinded .............. 15 
1.8 Definitions ......................................................................................................................... 15 
 
ANALYSIS POPULATIONS .............................................................................................. 17 
2.1 Intent-to-Treat (ITT) Population ....................................................................................... 17 
2.2 Safety Population ............................................................................................................... 17 
2.3 Per Protocol (PP) Population ............................................................................................. 17 
 
STUDY ASSESSMENTS and DATA COLLECTION ....................................................... 18 
3.1 The Modified Rankin Scale ............................................................................................... 18 
3.2 Mortality ............................................................................................................................ 18 
3.3 Worsening of Stroke .......................................................................................................... 18 
3.4 National Institutes of Health Stroke Scale ......................................................................... 18 
3.5 Volume of Stroke ............................................................................................................... 18 
3.6 Barthel Index ..................................................................................................................... 19 
3.7 EQ-5D-5L .......................................................................................................................... 19 


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MISSING DATA AND DATA TRANSFORMATION ...................................................... 20 
4.1 Statistical Methods ............................................................................................................ 20 
4.2 Estimands ........................................................................................................................... 20 
4.3 Missing Data ...................................................................................................................... 21 
4.3.1 Imputation of Mortality and Worsening of Stroke.................................................... 21 
4.3.2 Imputation of mRS Score .......................................................................................... 21 
4.3.3 Imputation of NIHSS and BI data ............................................................................. 23 
4.4 Data Transformation .......................................................................................................... 24 
4.5 Pooling of Sites .................................................................................................................. 24 
4.6 Pooling of Data from the Two Time-to-Randomization Strata ......................................... 24 
 
DISPOSTION AND DEMOGRAPHICS ............................................................................. 25 
5.1 Subject Disposition ............................................................................................................ 25 
5.2 Protocol Violations ............................................................................................................ 25 
5.3 Treatments ......................................................................................................................... 25 
5.4 Study Progress Time .......................................................................................................... 26 
5.5 Demographic and Baseline Characteristics ....................................................................... 26 
 
EFFICACY ANALYSIS ...................................................................................................... 27 
6.1 Primary Outcome Variable Analysis for Main Study ....................................................... 27 
6.1.1 Primary Estimand ...................................................................................................... 27 
6.1.2 Statistical Hypothesis ................................................................................................ 27 
6.1.3 Primary Efficacy Estimand Analysis ........................................................................ 27 
6.2 Secondary Efficacy Estimand Analyses for Main Study ................................................... 30 
6.2.1 Mortality ................................................................................................................... 31 
6.2.2 Worsening of Stroke ................................................................................................. 31 
6.2.3 Secondary Outcome Analysis – mRS shift analysis ................................................. 31 
6.2.4 National Institutes of Health Stroke Scale ................................................................ 33 
6.3 Tertiary Efficacy Outcomes Analyses for Main Study ..................................................... 33 
6.3.1 Volume of Stroke ...................................................................................................... 33 
6.3.2 Barthel Index ............................................................................................................. 34 
6.3.3 Proportion of subjects with Day 90 mRS 4-6 ........................................................... 34 
6.3.4 Proportion of subjects with Day 90 mRS ≤ 1 ........................................................... 34 
6.3.5 EQ-5D-5L ................................................................................................................. 34 
6.4 Exploratory Analyses for Main Study ............................................................................... 34 


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6.5 Pharmacokinetic Analyses ................................................................................................. 35 
6.6 Outcome Analysis for 1-Year Sub-Study .......................................................................... 36 
6.6.1 mRS at 1 Year ........................................................................................................... 36 
6.6.2 Mortality Rate at 1 Year ........................................................................................... 36 
6.6.3 Barthel Index at 1 Year ............................................................................................. 36 
6.6.4 EQ-5D-5L at 1 Year .................................................................................................. 36 
 
SAFETY ANALYSES.......................................................................................................... 39 
7.1 Adverse Events .................................................................................................................. 39 
7.2 Vital Signs ......................................................................................................................... 40 
7.3 Laboratory Results ............................................................................................................. 40 
7.4 Concomitant Medications .................................................................................................. 41 
 
INTERIM ANALYSIS ......................................................................................................... 42 
8.1 Interim Efficacy Analysis .................................................................................................. 42 
8.2 Safety Analysis .................................................................................................................. 44 
8.3 Independent Data Monitoring Committee ......................................................................... 44 
8.4 Handling of Enrollment Overage ...................................................................................... 45 
 
Supporting Documentation ................................................................................................... 46 
9.1 Appendix 1: Listing of Treatment-Emergent AEs of Special Interest (TEAESI) ............. 46 
9.2 Appendix 2: List of Abbreviations .................................................................................... 48 
 REFERENCES ..................................................................................................................... 50 
 
LIST OF TABLES 
Table 1: Objectives and Endpoints ................................................................................................. 9 
Table 2: Schedule of Activities- Main Trial ................................................................................. 14 
Table 3: Schedule of Activities: One-Year Follow Up Telemedicine or Telephone Contact ...... 14 
Table 4: Summary of Inferential Efficacy Analyses ..................................................................... 37 
Table 5: Summary of Interim Efficacy Analyses ......................................................................... 42 
 


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INTRODUCTION   
This document provides the details of statistical analyses planned for Protocol No. NA-1-009/ 
ESCAPE-NEXT.  In addition, it discusses the statistical issues relevant to these analyses 
(e.g., sample data to be used and missing data). 
1.1 
Background 
Nerinetide (formerly termed NA-1 or TatNR2B9c) is a synthetic, cell-permeant eicosapeptide 
(20 amino acids) that perturbs protein-protein interactions on the cytosolic surface of the cell 
membrane mediated by post-synaptic density 95 protein (PSD-95)1, an abundant protein 
localized in post-synaptic densities of central nervous system neurons.  It may provide significant 
benefit for the treatment of acute cerebral ischemia if administered to stroke patients who present 
to medical attention before infarction is complete. The rapid progression of irreversible brain 
injury in most acute strokes implies a short window of clinical efficacy of any treatment, 
including nerinetide. The ability to identify patients with salvageable brain using the criteria used 
in the ESCAPE trial2 provided an opportunity to target patients who may have the greatest 
benefit from neuroprotection, and to enhance further the impact of reperfusion therapies3. This 
led to the ESCAPE-NA-1 trial which used inclusion/exclusion criteria substantially similar to 
those of ESCAPE in order to select potential responders to neuroprotection by nerinetide. Results 
obtained from the ESCAPE-NA1 trial4 suggested that nerinetide may be effective in enhancing 
functional independence, reducing mortality, and reducing infarct volumes in participants with 
AIS who were selected for EVT provided that they had not received alteplase, a thrombolytic 
agent indicated in some stroke patients.  Our preclinical and clinical data support this notion. 
The rationale for the present study is as follows: 
1) The ESCAPE-NA1 trial (protocol NA-1-007) provided promising evidence that, in 
participants with AIS who were selected for EVT and who did not receive the thrombolytic 
alteplase, treatment with nerinetide increases functional independence and reduced stroke 
mortality4. This was supported by a reduction in infarction volume as measured by MRI or 
CT scanning. Since these improvements were observed in three separate domains of 
outcome (functional independence, mortality, and infarction volumes), they are unlikely to 
be due to chance alone. The present study is intended to explore these findings further.  
2) Participants in ESCAPE-NA1 who did receive alteplase as part of their care did not benefit 
from subsequently being administered nerinetide. This was likely due to the degradation 
of nerinetide by circulating plasmin, the product of prior alteplase administration. This 
hypothesis was supported by pharmacokinetic data from a subset of participants in the trial 
that showed that those who received alteplase had reduced plasma levels of nerinetide 
(approximately 60% reduction) as compared to participants who did not receive alteplase. 
The magnitude of this reduction or its clinical impact could not have been anticipated from 
prior studies in animals.  
3) Nerinetide does not have thrombolytic or thrombotic properties of its own5 and does not 
interfere with the activity of thrombolytic agents such as alteplase or tenecteplase. It has a 
plasma half life of about 5-10 minutes after which it is redistributed to extravascular tissues. 
Because it is a peptide, it is cleaved by proteases. Preclinical studies have shown that 
plasmin, which has similar substrate specificity to trypsin, cleaves nerinetide into several 
fragments beginning at its N-terminus5. It is similarly cleaved when it is combined in 
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These same preclinical studies have shown that co-administration of nerinetide with high-
dose alteplase (6x the human dose) can nullify the neuroprotective effectiveness of 
nerinetide in a rat model of embolic middle cerebral artery occlusion (eMCAO). However, 
due to its short half-life it can be administered in preclinical studies before alteplase and 
this restores its efficacy in eMCAO, and may be synergistic with alteplase5. The drug-drug 
interaction between nerinetide and alteplase has led to the exclusion of participants who 
are candidates for alteplase in the ESCAPE-NEXT trial.  
4) Based on data from preclinical studies, the Phase 1 (protocol NA-1-001) safety study, the 
Phase 2 ENACT trial6 (protocol NA-1-002) and the Phase 3 ESCAPE-NA1 study4 
(protocol NA-1-007), nerinetide is expected to be have an acceptable safety profile. 
5) There is a compelling need to develop neuroprotectants in order to increase the proportion 
of patients who may benefit from EVT. These agents could improve the outcomes of 
patients and render more patients with AIS into candidates for endovascular or 
pharmacological recanalization treatment.  
6) The current study is intended to confirm the findings in the ESCAPE-NA1 trial that 
nerinetide may improve functional independence, reduce mortality, and reduce infarction 
volumes in participants with AIS who are selected for EVT and who are not treated with 
thrombolytics.  
1.2 
Trial Objectives 
1.2.1 Primary Objective 
The primary objective is to determine the efficacy of the neuroprotectant, nerinetide, in reducing 
global disability in subjects with major acute ischemic stroke (AIS).  
1.2.2 Secondary Objectives 
The secondary objectives are to determine the efficacy of nerinetide in: 
1) Reducing mortality rate 
2) Reducing worsening of stroke* 
3) Reducing functional dependence 
4) Improving neurological outcome 
* Worsening of stroke is defined as (A) progression, or hemorrhagic transformation, of the index 
stroke as documented by medical imaging that is (a) life-threatening requiring intervention 
and/or (b) results in increased disability as gauged by a ≥4 point increase from lowest NIHSS 
during hospitalization and/or (B) results in death from the index stroke.  
1.2.3 Tertiary Objectives 
The tertiary objectives are to determine the efficacy of nerinetide in: 
• Decreasing infarct volume 
• Improving activities of daily living 
• Reducing dependency or death 
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1.2.4 Safety Objectives 
The safety objectives are to determine the effect of administering a dose of 2.6 mg/kg (up to a 
maximum dose of 270 mg) intravenous infusion of nerinetide to participant with acute stroke on 
SAEs and 90-day mortality. 
1.2.5  1- Year Follow Up Analytic Sub-Trial Objectives 
There will be a 1-Year follow-up analytic sub-trial to support the outcomes obtained at Day 90.  
The primary objective is to determine the efficacy of the neuroprotectant, nerinetide in:  
• Reducing global disability in participants with acute ischemic stroke (AIS). 
The secondary objectives are to determine the efficacy of nerinetide in: 
• Reducing mortality rate 
• Improving activities of daily living 
• Improving health related quality of life 
 
Table 1: Objectives and Endpoints 
Objectives 
Endpoints* 
Primary 
Reducing global disability in subjects 
with acute ischemic stroke (AIS). 
The primary outcome is the proportion of participants 
with independent functioning on the modified Rankin 
Scale (mRS), as defined by a score of 0-2 at Day 90 
post randomization.  These participants are defined to 
be responders. 
Secondary 
Reducing mortality rate. 
A reduction in mortality rate, as defined by event rate 
(proportion, expressed as a percentage) for mortality 
over the 90-day study period. 
Reducing worsening of stroke**. 
Proportion of participants with worsening of stroke 
over the 90-day study period. 
Reducing functional dependence. 
A shift of one or more categories to reduced 
functional dependence analyzed across the whole 
distribution of outcomes on the mRS at Day 90 post 
randomization. 
Improving neurological outcome.  
Proportion of participants with good neurological 
outcome, as defined by a score of 0-2 on the NIHSS 
at Day 90 post randomization. 
Tertiary/Exploratory 
Decreasing infarct volume. 
Volume of stroke as measured by MRI or CT brain 
imaging (MRI preferred). 
Improving activities of daily living. 
Proportion of participants with functional 
independence in activities of daily living, as defined 


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by a score of ≥ 95 on the Barthel Index (BI) at Day 
90 post randomization. 
Reducing dependency or death. 
Proportion of participants with reduced moderate or 
severe disability or death, as defined by a score of 4-
6 on the mRS at Day 90 post randomization. 
Improving excellent functional outcome Proportion of participants with excellent functional 
outcome, as defined by a score of 0-1 on the mRS at 
Day 90 post randomization 
Improving health related quality of life. 
Health-related quality of life, as measured by the EQ-
5D-5L at Day 90. 
Safety 
To determine the safety based on 
serious adverse events (SAEs).  
Proportion of subjects with serious adverse events to 
Day 90. 
90-day mortality. 
Proportion of subjects alive at 90-day. 
1 Year Follow Up 
Primary 
Reducing global disability in 
participants with acute ischemic stroke 
(AIS). 
The proportion of participants with independent 
functioning on the modified Rankin Scale (mRS), as 
defined by a score of 0-2 at 1-year. 
Secondary 
Reducing mortality rate 
A reduction in mortality rate, as defined by event rate 
(%) for mortality over the 1-year study period. 
Improving activities of daily living 
The proportion of participants with independent 
function on activities of daily living defined on the 
modified Barthel Index (BI) with a score of ≥ 95 at 1-
year. 
Improving health related quality of life. 
Health-related quality of life, as measured by the EQ-
5D-5L at 1 year. 
* Imputation for missing data up to Day 90 and for the 1-year follow up will be conducted as per 
Section 4.3 of this SAP.   
**Worsening of stroke is defined as (A) progression, or hemorrhagic transformation, of the index 
stroke as documented by medical imaging that is (a) life-threatening requiring intervention and/or 
(b) results in increased disability as gauged by a ≥4 point increase from lowest NIHSS during 
hospitalization and/or (B) results in death from the index stroke. 
 
 
 


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1.3 
Study Design 
This study is a Phase 3, randomized, multicentre, blinded, placebo-controlled, parallel group, 
single-dose, adaptive design with a single interim analysis for unblinded sample size re-
estimation. Because AIS is a medical emergency, the trial is designed to enable the 
administration of standard-of-care treatments without delay in order to save the life of the person 
concerned, restore good health or alleviate suffering. 
Participants harboring an acute ischemic stroke who are selected for endovascular 
revascularization without intravenous or intra-arterial thrombolytic therapy will be given a 
single, 2.6 mg/kg (up to a maximum dose of 270 mg) intravenous dose of nerinetide or placebo. 
Randomization will be stratified by time from stroke onset to randomization ≤ 4.5 hours (yes/no) 
and done with stochastic minimization to balance baseline factors within strata. The end of the 
main trial is defined as the date that the last enrolled participant has completed their Day 90 
visit/contact. For the purpose of an analytic follow-up sub-trial component, participants will be 
contacted by telemedicine or telephone at 1-year by individuals blinded to the outcome of the 
main trial.   
An initial target 680, and up to 1020, male and female participants aged 18 years and older 
harboring AIS and who are selected for endovascular revascularization without intravenous or 
intra-arterial thrombolytic therapy will be enrolled. A patient who consents but is not randomized 
will be considered a screen failure. A subject is considered randomized the moment the real-time 
web-based randomization process is completed. This is time zero for the subject. All subjects 
will be followed for 90 days (or until death if prior to 90 days).  Subjects who are randomized 
but do not receive study drug will still be followed through the 90-day study period. The end of 
the pivotal study is defined as the date that the last enrolled subject has completed their Day 90 
visit. 
At Day 30 and Day 90 it is preferred that participants will return to clinic.  If an in-clinic visit is 
not possible the participant can be contacted by telemedicine (preferred) or by telephone (last 
option).  
Participants will be followed at 1-year for the analytic sub-trial for further outcome assessment 
by telemedicine or telephone interview conducted by individuals blinded to the outcome of the 
main trial.  This sub-trial will be conducted to explore the independent functioning and quality of 
life at 1-year.  This sub-trial will be reported separately from the main trial. 
Subjects will be followed at 1-year for further outcome assessment by telephone interview 
conducted by individuals blinded to the outcome of the main study. The Schedule of 
Assessments for the main trial is presented in Table 2 and for the 1-Year follow up in Table 3. 
Two database locks and corresponding reports are planned for this trial. The first report will be 
based on the completion of Day 90 visits for the main trial. The second report will be following 
the completion of the 1-Year follow up for the analytic sub-trial. 
1.4 
Sample Size Determination  
The primary efficacy outcome variable for the pivotal assessment of efficacy is the overall 
proportion of participants experiencing a favorable functional outcome 90 days post-
randomization, defined as a score of 0 to 2 on the modified Rankin Scale (mRS). These 
participants are defined to be responders. 


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An initial target 680, and up to 1020, male and female participants aged 18 or older harboring 
AIS and who are selected for endovascular revascularization without intravenous or intra-arterial 
thrombolytic therapy will be enrolled. 
Based on results of ESCAPE-NA1 and assuming a 50% overall responder rate for the placebo 
group, there will be approximately 82% power to detect an 11.4% absolute effect difference 
between response rate (proportion of responders, with Day 90 mRS in the range 0 to 2) with 
nerinetide and placebo, at alpha level 0.05 2-sided. 
This sample size was calculated via simulation under the assumption of 2% probability of 
dropout and 50 patients per month accrual during the trial (across both arms) using the Chen-
DeMets-Lan  approach7 for unblinded sample size re-estimation, and possible early stopping for 
overwhelming superiority with an O’Brien-Fleming alpha spending boundary at a single interim 
analysis with a maximum sample size of 1020 evaluable (inflation factor 1.5) and inflation in the 
“promising zone” based on conditional power between 50% and 81%, based on the observed 
trend at the interim and using a Wald statistic with target conditional power after sample size 
increase 81% (using an increase rule to be specified in the IDMC Charter to prevent back-
calculation of interim effect sizes after the interim analysis). The interim analysis is planned to 
take place at 75% information (primary endpoint), i.e. when approximately 510 of the initial 
target 680 patients have reached their primary endpoint assessment. With these specifications, 
the study will have approximately 82% power for the primary analysis using standard Wald 
statistic for comparison of 2 independent proportions (EaST v6.5 2020). The cumulative alpha 
spent at the interim analysis is 0.01 and final analysis 0.025, 1-sided; the stopping boundaries on 
the Z scale are 2.34 (interim) and 2.012 (final) and on the p-value scale 0.01 (interim) and 0.022 
(final), all on the assumption that the interim is conducted at 75% information (EaST v6.5, 
2020). 
See Section 8 for further details on the interim analysis. 
1.5 
Randomization 
Treatments (placebo vs. nerinetide) will be assigned 1:1 by application of a minimization 
algorithm administered through a secure web-based, real-time interaction with the site and the 
central server. The time of randomization on the central server will be considered baseline (i.e., 
time zero) for the study. Study drug is intended to be infused as soon as possible after qualifying 
imaging and randomization. Although each vial of nerinetide or placebo will have a unique 
identification number that will be linked to the randomization code generated by the 
minimization algorithm, the vials will appear to be identical to those dispensing them and to the 
subjects. Thus, individuals at the sites will be blinded to the treatment assignments. 
In order to balance the treatment assignment among subjects enrolled at various times from 
stroke onset, treatment will be assigned using 1:1 randomization (nerinetide:placebo) with a 
stratification based on time from stroke onset to randomization of less than or equal to 4.5 hours 
(yes/no) and a randomized minimization algorithm to minimize the contribution of imbalances in 
baseline factors (age, sex, baseline NIHSS score, baseline ASPECT score, occlusion location, 
time from qualifying imaging to randomization, and site). The time of 4.5 hours was selected as 
it approximates the median time to randomization from the ESCAPE-NA1 trial.  
There will be 2 randomization strata: 
• Comprising subjects enrolled at a time of less than or equal to 4.5 hours from stroke 


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symptom onset. 
• Comprising subjects enrolled at a time greater than 4.5 hours from stroke symptom onset. 
Randomization will be by the minimally sufficient minimization procedure of Zhao8.  The 
procedure will be implemented to achieve balance on 7 baseline subject-level prognostic 
variables: age, sex, baseline NIHSS scores, baseline ASPECT score, occlusion location, time 
from qualifying imaging to randomization and study site. At the time of randomization, subject 
age will be calculated using the central server date and time. This overall approach will ensure 
that the subjects entered into the trial will be matched on the seven key prognostic covariates, 
within strata and between treatment arms, thereby minimizing the likelihood of chance 
confounding the estimates of the treatment effects with covariate effects. In addition to ensuring 
a balanced analysis at the conclusion of the study, the minimization will also provide some 
assurance that adequate balance will be maintained at the time of interim analysis. 
The randomization of the first 50 subjects will be completed using a simple random number 
generator to yield an unstratified randomization, with each subject having an equal probability of 
assignment to either treatment arm. Thereafter, randomization will be stratified as described 
above, with the minimization algorithm applied to achieve balance simultaneously across the 
covariates.  
All subjects who are randomized will be accounted for in the trial database and followed 
rigorously for the primary and key secondary outcomes to minimize issues of imputation/missing 
data. The randomization number and time will be automatically generated from the 
randomization website and will be transmitted to the central trial database to create the case in 
the electronic case report form.  The randomization date, time, the stratification variable, and the 
6 covariates for the minimization algorithm will not be editable once a subject is randomized.  
The automated system will inform site staff when re-stocking of the refrigerator containing study 
drug is required and will specify the vial numbers to be restocked. This will ensure that a blinded 
investigator cannot match a vial that was just given to a subject to a single re-stocked vial and 
adds to the assurance of the study blind. Re-stocking from the local pharmacy will take place 
within one business day and as per the local participating site’s working practice. 
All subjects, investigators, their clinical staff, the clinical coordinating center, the data 
management group, and the sponsor staff and delegates will be blinded to the randomization 
codes. The local laboratories will also be blinded. 
 


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Table 2: Schedule of Activities- Main Trial 
Visit/Contact 
V1 
V2 
V3 
V4 
V5 
V6 
Day 
Day 1 
Baseline 
Day 1 
Post-EVT 
Day 2/3 
Day 61 or 
discharge 
Day 302 
Day 902 
Window 
 
(~2 h) 
(18-56 h) 
 
(±5 d) 
(-21 to +7d) 
Informed consent 
X 
 
 
 
 
 
Regained capacity informed consent3 
 
 
X 
X 
X 
X 
History and physical examination 
X 
 
 
 
 
 
Weight4 
X 
 
 
 
 
 
Vital Signs (BP, HR, Temperature) 5 
X 
X 
X 
 
 
 
Randomization/  
Study drug administration 
X 
 
 
 
 
 
Mortality 
 
X 
X 
X 
X 
X 
NIHSS 
X 
X 
X 
X 
X 
X 
mRS6 
X 
 
 
X 
X 
X 
Barthel Index 
X 
 
 
 
X 
X 
EQ-5D-5L 
 
 
 
 
 
X 
Qualifying Imaging 
X 
 
 
 
 
 
Endovascular Procedure 
X 
 
 
 
 
 
MRI/NCCT head7 
 
 
X 
 
 
 
Laboratory Assessments 
X8 
 
X 
 
 
 
Pregnancy test9 
X 
 
 
 
 
 
Pharmacokinetic samples10 
X 
 
 
 
 
 
AE  
Collected to Day 30 
 
SAE 
Collected to Day 90 
Prior medications 
X 
 
 
 
 
 
Concomitant medications 
Collected to Day 6 or discharge 
 
1. Visit will occur at Day 6 or hospital discharge if prior to Day 6.  
2. At Day 30 and Day 90 it is preferred that participants will return to clinic.  If a in clinic visit is not possible the participant 
can be contacted by telemedicine (preferred) or by telephone (last option). 
3. If the original process involved anyone other than the participant (and if required), site staff will make ongoing efforts until: 
(1) regained capacity consent is obtained from participant, (2) death, or (3) completion of the Day 90 assessment. 
4. At baseline estimated or actual weight will be collected. If an estimated weight was collected at baseline, actual weight should 
be collected as soon as feasible and prior to discharge. 
5. Vital signs (BP, HR only) will be recorded immediately before and after completion of the study drug infusion, temperature 
will be collected at baseline only if standard of care. 
6. Historical (pre-stroke) mRS score can be collected at any time.  
7. MRI head may be supplanted by an NCCT head if MR is unavailable or contraindicated.   
8. Blood should be drawn at baseline, but results are not required prior to randomization. Results from primary hospital (within 8 
hours) are accepted. 
9. If the participant is female and is of childbearing potential a pregnancy test (urine or serum point-of-care pregnancy test) must 
be completed and the result must be negative; this is the only mandatory laboratory test prior to randomization. 
10. PK samples will be collected from up to 100 participants: pre-dose and at 10, 20, 30 and 60 min after the start of study drug 
administration. 
d = days; h = hours 
 
 
Table 3: Schedule of Activities: One-Year Follow Up Telemedicine or Telephone Contact 
Contact 
V7- One-Year Follow up  
Day (Window) 
Day 365 (±30 d) 
Mortality, EQ-5D-5L, mRS, Barthel Index 
X 
 
1.6 
Blinding of Main Study 
The study is conducted in a blinded manner. All subjects, investigators, their clinical staff, the 
clinical coordinating center, the data management group, and the sponsor staff and delegates will 


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be blinded to the randomization codes. The local laboratories will also be blinded.  
The IDMC reports and analyses for Closed Sessions will be organized by treatment arm 
(“unblinded”). In order to ensure confidentiality and minimize bias, the information will be 
provided to the IDMC by an unblinded statistician from a group that is independent of the 
sponsor and the blinded project team implementing the trial. A firewall will be maintained 
between the IDMC and statistician (unblinded) and the project staff (blinded).  The IDMC will 
review safety data and other data as requested by the IDMC, in addition to the interim analysis 
results. 
The person responsible for the study drug labelling will be unblinded, as will the independent 
statistical group preparing the reports for the IDMC. The person responsible for the data 
management group, who manages the programming of the randomization system will be 
unblinded. This individual will be the contact person if unblinding is necessary. This individual 
will not participate in data management and will only communicate unblinded data as set out 
below when contacted by the medical monitor. 
Otherwise, randomization data will be kept strictly confidential, accessible only to authorized 
persons, until the time of unblinding after data lock at the time of interim analysis and at end of 
the study. 
In case of emergency, a rapid unblinding procedure is available to investigators.  If the 
investigator decides that the treatment code needs to be broken in the interest of subject safety, 
the investigator will have direct access to the study data management center to request 
unblinding of the specific subject. The data management center will respond in writing to the 
investigator only with the unblinded patient treatment allocation.  
Only the investigator requesting the unblinding will receive the unblinding information. The 
investigator will promptly inform the Sponsor when a request to unblind is made and the 
circumstances involved.  Any case that is unblinded in this way will be documented in a blinded 
manner in central study files. 
1.7 
Blinding of 1-year Follow-up Study 
It is anticipated that a proportion of subjects enrolled in the Main Study will have reached their 
1-year follow-up before the Main Study is unblinded. That proportion will depend on the rate of 
enrollment in the Main Study.  
1.7.1 Subjects having the 1-year Follow-up While the Main Study is Blinded 
Subjects whose 1-year follow-up occurs while the Main Study is still blinded will be contacted 
for telephone follow-up by study staff who are blinded to treatment allocation. 
1.7.2 Subjects having the 1-year Follow-up After the Main Study is Unblinded 
Subjects whose 1-year follow-up occurs after the Main Study is unblinded will be contacted for 
telephone follow-up by study staff who are firewalled from previous study staff who have 
become unblinded to treatment allocation. Specifically, such study staff will be firewalled from 
the Sponsor, the IDMC, the unblinded statistician, and the coordinating investigators.  
1.8 
Definitions 
Baseline: A subject’s baseline value for a given endpoint or parameter is defined as his/her latest 
measurement taken prior to study drug administration. 


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Prior and Concomitant Medications: Prior medications are defined as those taken within 24 
hours prior to randomization. Concomitant medications are defined as those taken during study 
drug administration or after study drug has been administered through to Day 6 (or discharge). 
All prior and all concomitant medications will be recorded on the electronic case report form.  
Randomization: The time of randomization is defined as the time randomization occurred on 
the central server and this time is considered time zero for the study. All time windows are 
calculated from the time of randomization. 
Study Day: Day 1 is the date of randomization. As the study drug is intended to be administered 
as soon as possible after randomization (i.e., 15 minutes), this will also be the day of treatment 
initiation date. Study day is calculated relative to Day 1. 
Treatment-Emergent Adverse Event: All AEs will be collected from the start of study drug 
administration until Day 30. All SAEs will be collected from the start of study drug 
administration until Day 90. A treatment-emergent adverse event (TEAE) is one that first occurs 
or worsens in severity or frequency after study drug administration has begun through to and 
including the Day 30.  SAEs are collected through the last study visit. Those AEs that start at the 
same time and date as the study drug administration and those that first occur or worsen after the 
start of study drug administration will be considered TEAEs. 
AEs with partial or missing dates will be handled as follows: 
• If the start day and/or month of the AE is missing the AE will be considered treatment-
emergent. 
• If the start date is completely missing then the AE will be considered treatment-emergent. 
 
 


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ANALYSIS POPULATIONS 
This study is designed to address a population of adults 18 years and older harboring an acute 
ischemic stroke who are selected for endovascular revascularization without intravenous or intra-
arterial thrombolytic therapy who will receive a single, 2.6 mg/kg (up to a maximum dose of 270 
mg) intravenous dose of nerinetide or placebo. 
2.1 
This is a global trial being conducted under the same protocol at clinical sites in 
different countries in accordance with the national legislation of the country in which 
the trial is carried out. Following the completion of the study and provided that the 
requirements of 21CFR 312.120 are met, data from all study sites will be pooled for 
the purpose of analyses in this statistical analysis plan.Intent-to-Treat (ITT) 
Population  
The primary efficacy analysis will be conducted on the ITT population, defined as all subjects 
randomized into the trial with grouping by randomized treatment, regardless of treatment 
actually received. Deceased subjects will be included in the ITT population with a mRS score of 
6, NIHSS of 42 and Barthel Index of 0. An ITT analysis will also be conducted for the secondary 
endpoints, with subjects grouped according to the randomized (intended) treatment. 
2.2 
Safety Population  
The safety population comprises all subjects receiving any amount of study drug. In safety 
analyses, subjects will be grouped according to treatment actually received. 
2.3 
Per Protocol (PP) Population 
The primary analysis will be repeated on the Per Protocol (PP) population, defined to be all 
subjects randomized and treated, with no major protocol deviations. We define “major protocol 
deviations” as those with the potential to bias, confound, or otherwise obscure the treatment 
effect estimates or which involve ethical standards. This population will be determined via a 
blinded review of protocol deviations at the end of the trial before database lock and unblinding. 
Missing data due to death during the study will not exclude a patient from the PP population (i.e. 
death is not considered a major protocol violation). 
Prior to unblinding, the imaging from each subject at the time of inclusion will be adjudicated to 
determine whether they have met the criteria for endovascular intervention and the imaging 
inclusion criteria, and hence for the trial.  This will include review of baseline NCCT, CTA and 
if performed CTP or MRP. Subjects who do not meet the imaging criteria outlined in the trial 
inclusion/exclusion criteria will be reviewed in a blinded fashion as described above to 
determine if they met the criteria. 
Participants will be excluded from the per-protocol analysis for the following violations:  
• did not meet inclusion/exclusion criteria,  
• did not receive planned dose volume,  
• incorrect study drug vial,  
• infusion more than 15 minutes,  
• consent not obtained (including incorrect Deferral of Consent where applicable). 


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STUDY ASSESSMENTS AND DATA COLLECTION 
Study procedures and their timing are summarized in the Table 2: Schedule of Activities.   
3.1 
The Modified Rankin Scale 
The primary endpoint used in this trial will be global disability, as measured by the mRS, at Day 
90. The mRS is a valid and reliable clinician-reported measure of global disability that has been 
widely applied for evaluating recovery from stroke. It is a scale used to measure functional 
recovery (the degree of disability or dependence in daily activities) of people who have suffered 
a stroke9,10. mRS scores range from 0 to 6, with 0 indicating no residual symptoms; 5 indicating 
bedbound, requiring constant care; and 6 indicating death.  
The post dose mRS will be obtained at Day 6 (or discharge), Day 30 and Day 90 and at the One-
Year follow up.  Premorbid mRS status may be obtained at any time, but ideally at the Day 1 or 
2 visit.  The mRS will only be scored by those trained and certified (via 
www.healthcarepoint.com) in the use of this scale.  An Electronic Clinical Outcome Assessment 
(eCOA) tool may be used to conduct this assessment. 
3.2 
Mortality  
Mortality status will be obtained at all visits during the 90-day study period and at the One-Year 
follow up. Specifically, it will be assessed at Day 6 or discharge and at Days 30 and 90. Mortality 
rate is defined as the number of deaths observed divided by the number of subjects observed over 
the 90-day study period between nerinetide and placebo control subjects. 
3.3 
Worsening of Stroke 
Worsening of stroke is defined as (A) progression, or hemorrhagic transformation, of the index 
stroke as documented by medical imaging that is (a) life-threatening requiring intervention 
and/or (b) results in increased disability as gauged by a ≥4 point increase from lowest NIHSS 
during hospitalization and/or (B) results in death from the index stroke.  
3.4 
National Institutes of Health Stroke Scale 
The NIHSS is a standardized neurological examination score that is a valid and reliable measure 
of disability and recovery after acute stroke11.  Scores range from 0 to 42, with higher scores 
indicating increasing severity. The scale includes measures of level of consciousness, extra 
ocular movements, motor and sensory tests, coordination, language and speech evaluations.  The 
NIHSS will be administered at Baseline, Post-EVT (2 Hours), Day 2, Day 6 (or discharge), Day 
30 and Day 90. The NIHSS will only be scored by those trained in the use of this scale. An 
eCOA tool may be used to conduct this assessment. The NIHSS scores will be dichotomized into 
0-2 (indicating a good neurological outcome) versus >2 (indicating otherwise). 
3.5 
Volume of Stroke 
All subjects will undergo a follow-up brain MRI [including a minimum of axial DWI, gradient-
echo (GRE), FLAIR] at Day 2 (18 to 56 hours from the time of randomization).  The Day 2 MR 
is considered a standard of care imaging procedure; if MR is unavailable, then NCCT is allowed. 
The Day 2 MR (and where MR is unavailable, CT) will be used to assess infarct volume. Infarct 
volume determinations will be conducted before database lock. 


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Prior to database lock at 90 Days, the total volume of new strokes as measured by MRI or CT 
brain images (MRI preferred) in nerinetide versus placebo control participants will be calculated 
from the Day 2/3 imaging. Where MR is not available, infarct volumes will be determined from 
the Day 2/3 CT scan. The plan for combining CT and MRI data will be detailed in the Imaging 
Adjudication Charter.   
3.6 
Barthel Index  
The BI is an index of functional independence12 that is a valid measure of activities of daily 
living when employed in stroke trials13.  Modified BI scores range from 0 to 100, with higher 
scores indicating greater independence in activities of daily living and mobility. The BI will be 
scored at Baseline (pre-morbid), Day 30 and Day 90 and at the One-Year follow up, by those 
trained in the use of this scale.  Note that the original Barthel Index was a scale from 0-20.  The 
modified Barthel index simply multiplies the original scale by 5 to provide a 100-point score. An 
eCOA tool may be used to conduct this assessment. 
3.7 
EQ-5D-5L 
The EQ-5D-5L is a generic instrument for describing and valuing health. It is based on a 
descriptive system that defines health in terms of five dimensions: Mobility, Self-Care, Usual 
Activities, Pain/Discomfort, and Anxiety/Depression14. Each dimension has five response 
categories corresponding to: no problems, slight, moderate, severe and extreme problems15. The 
version of the instrument selected for the trial is interviewer administered either in-person, or by 
telemedicine or by telephone. The respondents will also rate their overall health on the day of the 
interview on a 0–100 visual analogue scale (EQ-VAS). The EQ-5D-5L will be administered at 
the Day 90 and at the One-Year follow up by those trained in the use of this scale. An eCOA tool 
may be used to conduct this assessment. 
 
 


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MISSING DATA AND DATA TRANSFORMATION 
4.1 
Statistical Methods 
The software used for all summary statistical analyses will be SAS® (SAS Institute, Inc.) version 
9.4 or later. 
Unless otherwise noted, categorical data will be summarized for each treatment group using 
counts and percentages, with the denominator for percentages being the number of subjects in 
the population of interest. Unless otherwise noted, continuous data will be summarized for each 
treatment group using the number of observations (n), mean, standard deviation (SD), median, 
minimum, and maximum. Some continuous data will be reported as the median, interquartile 
range (IQR), minimum and maximum according to the clinical meaning of the data. 
Percentages will be rounded to one decimal place, except 0% and 100% will be displayed 
without any decimal places. Minima and maxima will be rounded to the precision of the original 
value; means and medians will be rounded to one decimal place greater than the precision of the 
original value; standard deviations will be rounded to two decimal places greater than the 
precision of the original value. P-values will be reported to four decimal places (0.xxxx), with 
values less than 0.0001 presented as <0.0001. 
Inferential analyses will generally include statistics such as 2-sided 95% confidence intervals 
(CI), and p-values. 
The overall significance level for in this trial will be at two-sided 0.05. The type I error and the 
efficacy boundary for the final analysis will be adjusted accordingly based on the actual alpha 
spent at the interim analysis (details in Section 8).  
In order to protect the overall trial false positive rate, the primary efficacy analysis and secondary 
outcome analyses will be analyzed in a fixed sequence, stopping and calling all subsequent 
analyses exploratory (and accepting the null hypothesis) at the first failed hypothesis test in the 
sequence. The fixed sequential order is: 
1) Primary estimand 
2) Secondary estimands, as specified in the order presented in Section 4.2. 
4.2 
Estimands  
Death is an intercurrent event which may occur during the study. The fact that a participant has 
died may in itself be informative for quantifying the treatment effect, although data collections 
after death will not exist. Therefore, the primary and secondary estimands will be focusing on the 
composite strategy. More specifically, death will be incorporated as part of the primary and 
secondary estimands as described below and in Section 4.3. 
The primary estimand will be the difference in the mRS response (i.e., mRS score of 0-2) 
proportions between treatment conditions (nerinetide vs. placebo) in the target patient population 
at Day 90. Deaths occurring over the Day 90 period will be considered as non-response.   
The secondary estimands are defined below:  
• The difference in mortality rate over the 90-day period between treatment conditions in the 
target patient population.  
• The difference in worsening of stroke proportions between treatment conditions in the 


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target patient population over the 90-day period. Death meets the definition of worsening 
of stroke. 
• The difference in showing a shift in mRS categories between treatment conditions in the 
target patient population at Day 90. Death occurring prior to Day 90 will be assigned with 
the worst mRS score (score of 6). 
• The difference in NIHSS response (i.e., score of 0-2) proportions between treatment 
conditions in the target patient population at Day 90. Death occurring prior to Day 90 will 
be considered as non-response. 
4.3 
Missing Data  
Every effort will be made to keep missing data, particularly the Day 90 outcome assessments, to 
a minimum.  However, some missing data may be inevitable due to, for example, loss to follow-
up.  
All imputed values will be determined prior to database lock and conducting primary analyses 
via the rules documented prospectively in this Statistical Analysis Plan for the study.  
To incorporate death as part of the estimand definition following the composite strategy, 
deceased participant will be assigned a score 6 on the mRS, 42 on the NIHSS and 0 on Barthel 
Index and be counted as non-responders. In addition, deceased participants are considered as 
experiencing worsening of stroke. Thus, there will be no missing mRS, NIHSS, BI or worsening 
of stroke data due to death.   
No imputation is planned for safety data. Efficacy outcomes will be imputed using a data-
informed imputation as follows: 
4.3.1 Imputation of Mortality and Worsening of Stroke 
For the analysis of rate of mortality, for participants for whom the mortality status is not known 
at Day 90: 
• if they were alive at Day 30, then the subject will be imputed as alive at Day 90   
• if both the Day 30 and Day 90 mortality is status is missing, the participant will be imputed 
as Dead at Day 90.  
Worsening of stroke data will be imputed similarly:  
• if it’s unknown whether the subject experienced worsening of stroke by Day 90 while they 
did not report any worsening of stroke by Day 30, then the subject will be imputed as not 
experiencing worsening of stroke at Day 90.  
• if both worsening of stroke status is unknown at both Day 30 and 90, then the subject will 
be imputed as experiencing worsening of stroke at Day 90. 
No imputation will be done on the missing one-year follow-up mortality data. 
4.3.2 Imputation of mRS Score  
Deceased subjects will be assigned scores of 6 on the mRS.  
Single Imputation (SI): To follow the composite strategy, the following approach will be used 
to impute missing mRS data at Day 90: 


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• if the participant is known to be dead at Day 90, they will be considered to be a non-
responder and the mRS will be imputed as 6 
• if the mRS was obtained at the Day 30 assessment or later and the participant is documented 
to be alive or the mortality status is unknown at Day 90, the Day 30 (or later) assessment 
will be carried forward as the Day 90 mRS value  
• if both the Day 30 and Day 90 mRS scores are missing but the participant is documented 
to be alive at Day 90 they will be considered to be a non-responder and the mRS will be 
imputed as a 5 
• if both the Day 30 and Day 90 mRS scores are missing and the mortality status of the 
participant is unknown at Day 90 they will be considered to be a non-responder and the 
mRS will be imputed as a 6. 
If more than 5% subjects randomized are missing the mRS score at Day 90, additional 
imputation methods will be employed as follows: 
Multiple Imputation (MI): The multiple imputation method assumes a Missing-At-Random 
(MAR) mechanism, which is a reasonable assumption for missingness not due to death. For the 
MI model, 50 imputations will be generated using PROC MI of SAS®. Imputation will be 
performed using the Fully Conditional Specification (FCS) logistic regression model. For each of 
the 50 datasets, missing mRS responders status (yes or no) will be imputed using a logistic 
regression model including treatment group, the mRS responder status at prior post-
randomization visits, baseline mRS score, randomization stratification factor (time from stroke 
onset to randomization≤4.5 hours (yes/no)), age, sex, baseline NIHSS score, baseline ASPECT 
score, occlusion location, time from qualifying imaging to randomization. The seed to be used in 
all MI model is 20201009. The choice of 50 imputations is generally considered sufficient to 
provide accurate and stable imputed results given the amount of missingness expected in this 
trial21. 
Analysis of the primary outcome will then be performed for each of the relevant MI datasets. 
The results of the 50 analyses will be transformed into a normal statistic and combined into a 
single analysis using PROC MIANALYZE. Details see Section 6.1.3. 
Example SAS code for PROC MI is as follows: 
PROC MI DATA=ADMRS1 OUT=ADMRS2 SEED=20201009 NIMPUTE=50 NOPRINT; 
CLASS TRTP RANDTIME SEX BNIHSS BASPECT OCCLOC BASEMRS MRS2 
MRS4 MRS5 MRS6; 
FCS LOGISTIC(MRS4 = TRTP AGE RANDTIME SEX BASPECT OCCLOC 
BASEMRS / DETAILS); 
FCS LOGISTIC(MRS5 = TRTP AGE RANDTIME SEX BASPECT OCCLOC 
BASEMRS MRS4 / DETAILS); 
FCS LOGISTIC(MRS6 = TRTP AGE RANDTIME SEX BASPECT OCCLOC 
BASEMRS MRS4 MRS5 / DETAILS); 
VAR TRTP AGE SEX BNIHSS BASPECT OCCLOC RANDTIME IMA_TIME 
BASEMRS MRS2 MRS4 MRS5 MRS6; 
RUN; 


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In above code, TRTP represents the randomized treatment group,  BASEMRS = Baseline mRS 
score, MRS4 – MRS6 represents the binary mRS responder status at Day 6/discharge (Visit 4), 
Day 30 (Visit 5), Day 90 (Visit 6) respectively, BNIHSS = Baseline NIHSS score, BASPECT is 
the baseline ASPECT score (5-7 or 8-10), OCCLOC is the baseline occlusion location, 
RANDTIME is the time from stroke onset to randomization ≤ 4.5 hours (yes/no), IMA_TIME is 
the time from qualifying imaging to randomization. 
The imputation models may be modified based on the actual data if there is an issue in model 
convergence. 
Tipping Point Analysis: Tipping point analysis under missing not at random (MNAR) 
assumption will be performed as sensitivity analysis to assess the assumptions about the missing 
primary endpoint data. The tipping point analysis will apply a specified sequence of shift 
parameters that modify the imputed log odds of mRS response to non-response in the nerinetide 
group, as follows: 
1. Missing mRS responder status will be imputed 50 times, following the MI method 
described above, with adjustment to the log odds of mRS response to non-response by 
shift parameter S1 in the nerinetide group only. A negative adjustment assumes that a 
subject with missing response status is more likely to be a non-responder; a positive 
adjustment assumes the subject with missing response status is more likely to be a 
responder. The MNAR statement with the ADJUST option in PROC MI will be used to 
apply the shift parameter. 
2. Each of the 50 completed datasets applying the shift parameters will be analyzed using 
the primary analysis method as described in Section 6.1.3. 
3. The results from the 50 completed datasets will be combined for inference using PROC 
MIANALYZE. 
4. Repeat steps 1-3, with adjustment by a different shift parameter to the imputed log odds 
in the nerinetide group, as following: S1 = 0 (no shift), -0.2, -0.4, -0.6, -0.8, -1.0, -1.2, -
1.4, -1.6, -1.8, and -2.0. 
The shift parameters that result in a reversed study conclusion (i.e. from statistically significant 
to non-significant) will be flagged. Alternate series of shift parameters may be applied based on 
the actual data. 
The missing mRS data at one-year follow-up will be handled according to below: 
• If subjects are known to be dead before or at one-year follow-up visit, mRS will be assigned 
a score of 6 and counted as non-responders. 
• Other missing data not due to death will be imputed by the multiple imputation method as 
described above.  
4.3.3 Imputation of NIHSS and BI data 
No missing NIHSS or BI data due to death. Deceased participants will be assigned scores 42 on 
the NIHSS and 0 on the Barthel Index (BI) and be counted as non-responders.  
Missing NIHSS or BI data at Day 90 will be imputed using the last observation carried forward 
(LOCF) imputation as follows: 
LOCF: Participants who are missing NIHSS or BI endpoint data at Day 90 will have the last 


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recorded score carried forward, provided that this score was obtained at the Day 30 visit or later. 
Otherwise, the missing NIHSS or BI will be imputed to the median score obtained at Day 90 in 
the trial. 
For missing BI data at one-year follow-up visit: 
• If the subjects are known to be dead before or at one-year follow-up visit, BI will be 
assigned a score of 0.  
• Other missing BI data not due to death will be imputed to the median score obtained at one-
year follow-up in the trial. 
4.4 
Data Transformation 
No transformation of the data is planned other than for volume of stroke. Note that stroke 
volume data are often dispersed and highly non-normal and may be normalized with a cubic root 
transformation. No data transformation is planned for the primary analysis. 
4.5 
Pooling of Sites 
In order to avoid sparse sites (sites with fewer than 10 randomized subjects) and the potential for 
too many levels for the explanatory variable of “site”, sites within a geographic region (North 
America/Europe/Rest of World) with fewer than 10 randomized subjects will be pooled into a 
single pooled site for use in efficacy analyses. If a resulting pooled site still has fewer than 10 
randomized subjects, it will be further pooled with the smallest remaining unpooled site(s) from 
that geographic region. If the resulting pooled site still has fewer than 10 randomized subjects, it 
will be further pooled with the smallest pooled site from another geographic region. The process 
of pooling sites will be reviewed and finalized before the unblinding of the main trial for the Day 
90 analysis (i.e. first database lock as described in Section 1.3).  
If more than one batch of nerinetide is used in the clinical trial, data from all subjects from all 
sites in the trial, regardless of the nerinetide batch administered, will be pooled for the purpose of 
analyses in this statistical analysis plan. Data from different batches will be pooled following the 
demonstration of equivalent quality of the clinical trial material based on the established release 
and stability testing of the nerinetide drug product batches used in the trial.  
4.6 
Pooling of Data from the Two Time-to-Randomization Strata  
Since the randomization will be stratified by time from stroke onset to randomization ≤4.5 hours 
(yes/no), the assessment for treatment-by-stratification variable interaction to examine for effect 
modification will be performed via a log-binomial generalized linear model as described in 
Section 6.1.3. In addition, homogeneity of the randomization stratification factor will be tested 
via Breslow-Day statistic22. If there is no evidence for effect modification, then we will report 
the data for the entire cohort only.  If there is evidence for effect modification, the effect size for 
the primary, secondary and tertiary outcomes will be additionally reported by stratum. 
 
 


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DISPOSTION AND DEMOGRAPHICS 
5.1 
Subject Disposition 
Subject disposition will be summarized and tabulated for ITT, PP and Safety populations. The 
summaries will include the number and percentage of subjects that completed the study and 
those that terminated early from the study (i.e., left the study prior to the Day 90 visit).  Early 
terminations will be categorized by the reason for study discontinuation.  Death will not be 
considered early termination.  A tabulation of the number and percentage of subjects randomized 
will be summarized by site for the ITT population. 
Disposition will be listed by treatment arm and subject. 
5.2 
Protocol Violations 
Protocol violations used to exclude subjects from the per-protocol analysis will be derived from 
the data collected in the case report form. Protocol violations will be determined during a data 
review meeting prior to database lock. Participants will be excluded from the per-protocol 
analysis for the following violations:  
• Enrollment did not comply with inclusion/exclusion criteria 
• Subjects who did not receive a per-protocol dose including: did not receive planned dose 
volume, received an incorrect study drug vial, or received the study drug infusion over 
more than 15 minutes. 
• Consent not obtained (including incorrect Deferral of Consent where applicable). 
The number and percentage of subjects in the ITT population with protocol violations will be 
summarized by treatment group and overall.  These protocol violations will be listed by 
treatment arm and subject. 
5.3 
Treatments 
Per protocol, an intravenous solution of nerinetide 20mg/ml will be given to subjects with a body 
weight < 105 kg to achieve a final target dose of nerinetide 2.6 mg/kg. Subjects weighing 105-
120 kg will each receive a total dose of 270 mg of study drug (i.e., the entire 13.5 ml contained 
in the study drug vial).   
At the time of randomization, the dose will be calculated based on actual known weight (e.g., 
using an in-hospital scale) or on the subject’s estimated weight.  If the dosing weight was 
estimated, actual weight will be obtained by Day 5.  Discrepancies between the weight estimate 
and actual weight obtained may result in some subjects not receiving the correct actual dose.  
Site staff will record the total volume of nerinetide solution received by each subject and their 
weight at the time of dosing as well as the actual weight if an estimated weight was used.  The 
following measures of the timeliness of the interventions and of exposure will be computed as 
follows.   
1) Number and percentages of subjects who received any nerinetide 
2) Descriptive statistics for: 
• Time from stroke symptom onset to start of nerinetide infusion (minutes) 


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• Time from randomization to start of nerinetide infusion (minutes) 
• Time from NCCT to start of nerinetide infusion (minutes) 
• Duration of study drug infusion (minutes) 
• Duration of study drug infusion (categorical): < 9 minutes, 9-11 minutes, > 11 minutes 
• Actual administered volume of study drug (mL) 
• Dosing compliance (%) 
• Dosing compliance is calculated as actual administered volume of study drug divided by 
the baseline calculated volume of study drug * 100. The baseline calculated volume of 
study drug is the calculated volume based on the estimated or actual body weight at the 
time of randomization as recorded on the Case Report Form, 
• Number and percentages of subjects compliant with study drug, a subject is considered 
compliant with study drug if the percent dosing compliance is ≥ 75% and ≤ 125% of 
planned volume. 
All measures will be summarized for the ITT population; individual exposures will be listed by 
treatment arm and subject.   
5.4 
Study Progress Time 
The following study progress time parameters will be summarized by treatment group and 
overall on ITT Population. 
• Time from Stroke Onset to study drug infusion start (minutes) 
• Time from ESCAPE-NEXT hospital arrival to study drug infusion start (minutes) 
• Time from to study drug infusion start to initial reperfusion* (minutes) 
• Time from ESCAPE-NEXT hospital admission to hospital discharge (days) 
• Time in repatriation hospital (days) 
• Time in inpatient rehabilitation (days) 
*time of initial reperfusion is defined as the time logged for the first mTICI score.  
5.5 
Demographic and Baseline Characteristics 
Subject demographic and baseline characteristics will be summarized with descriptive statistics 
for each treatment group. Demographic variables include, but are not limited to: age, sex, race-
ethnicity, weight at time of dosing (in kg), and weight as determined in hospital (in kg).  Baseline 
characteristics include but are not limited to: age, sex, baseline NIHSS score, baseline ASPECT 
score, occlusion location, time from stroke symptom onset to randomization (hours), time from 
stroke symptom onset to randomization ≤4.5 hours (yes/no), time from qualifying imaging to 
randomization, unwitnessed stroke onset (yes/no), stroke-on-awakening (yes/no), and site. The 
summaries will be provided for the ITT, Per Protocol and Safety populations. Inferential 
statistics (i.e., p-values or CI) will not be provided for these data with the exception of the results 
of a Fisher’s Exact Test which will be performed for the stratification variable “Time from 
Stroke Onset to Randomization ≤ 4.5 hours” (yes/no)” in order to assess balance across treatment 
groups.  Demographics will be listed by treatment arm and subject. 
Relevant past medical history as well as prior and concomitant medications will be summarized 
and listed. 
 


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EFFICACY ANALYSIS 
Two separate efficacy analyses are planned for this trial. The first analysis will be based on the 
completion of Day 90 visits for the main trial as described in Sections 6.1 to 6.5 below. The 
second analysis will be following the completion of the 1-Year follow up for the analytic sub-
trial as described in Section 6.6 below.  
A priori, we will assess for treatment-by-stratification variable interaction to examine for effect 
modification (details below).  If there is no evidence for effect modification, then we will report 
the entire cohort only.  If there is evidence for effect modification, we will additionally report 
results by stratum. 
Efficacy analyses are summarized in Table 4: Summary of Inferential Efficacy Analyses. 
6.1 
Primary Outcome Variable Analysis for Main Study 
6.1.1 Primary Estimand 
The primary estimand is defined as the difference in the mRS response (i.e. mRS score of 0-2) 
proportions between treatment conditions (nerinetide vs. placebo) in the target patient population 
at Day 90. Death occurring prior to Day 90 will be considered as non-response.   
6.1.2 Statistical Hypothesis 
The primary hypothesis is: 
H0: πnerinetide = πplacebo  VS 
Ha: πnerinetide ≠ πplacebo 
Where πnerinetide and πplacebo are the nerinetide and placebo population proportions of responders, 
defined as subjects whose Day 90 mRS score is ≤ 2. 
6.1.3 Primary Efficacy Estimand Analysis 
Primary statistical analysis for primary estimand 
The primary analysis for the primary estimand will be conducted in the ITT population according 
to the randomized treatment. Missing data will be imputed following the single imputation 
approach in Section 4.3.2. 
The primary hypothesis to be tested is that administration of nerinetide will result in an increase 
in the proportion of mRS responders (as defined by a score of 0-2) at Day 90.  
The pivotal primary analysis will be conducted on the ITT population at the 2-sided 0.05 
significance level overall (for the trial), adjusted for the interim analysis per the O’Brien-Fleming 
boundary spending function.  
The pivotal main effects primary analysis will use a multivariable generalized linear model 
(GLM) using a binomial distribution with a log link to provide adjusted relative risk (log-
binomial regression). Adjustment will include the stratification covariate of time from stroke 
onset to randomization ≤4.5 hours (yes/no) and the randomized minimization (age, sex, baseline 
NIHSS score, baseline ASPECT score, occlusion location, time from qualifying imaging to 
randomization and pooled site).  
The main effects primary analysis will be supported by a further analysis in which the GLM used 
for the pivotal analysis also includes the interaction term (treatment by randomization 
stratification factor). If the interaction term is significant at the 0.05 level, we will additionally 


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repeat the primary analysis, sensitivity analyses, the supportive analyses described below, and 
the analyses for the secondary efficacy estimand analyses and tertiary efficacy outcome analyses  
for each stratum separately. If the interaction term is not significant at the 0.05 level, the data for 
each stratum will not be reported separately. 
If a binomial distribution model fails to converge, accepted methods using multivariable logistic 
or Poisson regression with robust error variance will be used to provide adjusted relative risk. 
Example SAS code for the log-binomial regression model as follows: 
PROC GENMOD DATA = ADMRS; 
CLASS TRTPN RANDTIME SEX BASPECT OCCLOC SITEGR1; 
MODEL CRIT1FN(event=”1”) = TRTPN RANDTIME AGE SEX BNIHSS 
BASPECT OCCLOC IMA_TIME SITEGR1 / DIST = BINOMIAL LINK=LOG; 
ESTIMATE “NA-1 vs. placebo” TRTPN 1 -1 / exp; 
RUN; 
Example SAS code for the Poisson regression model: 
PROC GENMOD DATA = ADMRS; 
CLASS TRTPN RANDTIME SEX BASPECT OCCLOC SITEGR1 USUBJID; 
MODEL CRIT1FN = TRTPN RANDTIME AGE SEX BNIHSS BASPECT 
OCCLOC IMA_TIME SITEGR1 / DIST = POISSON LINK=LOG; 
REPEAT SUBJECT=USUBJID / TYPE=IND; 
ESTIMATE “NA-1 vs. Placebo” TRTPN 1 -1 / exp; 
RUN; 
Where CRIT1FN is a numeric variable to indicate binary mRS responder status (1 = responder, 0 
= non-responder), TRTPN is a numeric variable for treatment group (1 = nerinetide group, 2 = 
placebo), USUBJID is the subject ID. 
The conditional treatment effect (i.e. relative risk) along with the 95% CI, as well as the 
corresponding Wald test statistics and p-value estimated from the above model will be reported. 
Actual proportions with and without independent functioning (i.e. mRS responders and non-
responders) will be reported. 
In addition, the unconditional treatment effect will be estimated and reported following below 
steps: 
1. Run the primary analysis model (adjusted log-binomial regression) as described above. 
2. For each subject, compute the model-based prediction of the probability of mRS response 
under nerinetide in both the nerinetide group and placebo group using each subject’s 
specific baseline covariates (i.e. as specified in the primary analysis model)  
3. Estimate the average response under nerinetide by averaging (across all subjects in the ITT 
population) the probabilities estimated in Step 2 
4. For each subject, compute the model-based prediction of the probability of mRS response 
under placebo in both the nerinetide group and placebo group using each subject’s specific 
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5. Estimate the average response under placebo by averaging (across all subjects in the ITT 
population) the probabilities estimated in Step 4 
6. The estimates of average mRS responses rates in the two treatment groups from Steps 3 
and 5 will be used to estimate the relative risk (i.e. unconditional treatment effect) 
The 95% CI of the unconditional treatment effect will be constructed using a nonparametric 
bootstrap resampling, with 1000 resamples and subject as the unit of resampling. Resampling 
will be done independently for the nerinetide and placebo subjects. For each resample, Steps 1-6 
will be repeated. The 95% CI of the unconditional treatment effect will then be determined from 
the distribution of resample relative risks. 
Sensitivity analyses for the primary estimand 
Sensitivity analyses in the ITT population will be conducted in which missing values are not 
imputed, i.e. observed cases (OC). In addition, the following analyses will be also be performed 
depending on the amount of missingness observed: 
• If ≤ 5% of participants randomized are missing the Day 90 mRS assessment, a sensitivity 
analysis will be performed for the primary estimand by using only participants having 
completed Day 90 mRS assessments. Participants who are known to be dead before or at 
Day 90 will also be included as non-responders. 
• If more than 5% participants randomized are missing the Day 90 mRS assessment: 
o  a sensitivity analysis will be performed for the primary estimand with missing data 
imputed by MI (refer to Section 4.3.2) 
o A tipping point analysis will be performed to assess the robustness of the MAR 
assumption about the missing primary outcome 
The sensitivity analysis performed on multiple imputed datasets will follow these steps: 
1. For each of the multiple imputed datasets, the primary analysis model, i.e. adjusted log-
binomial regression, will be performed. The log (relative risk) and the standard errors will 
be obtained. 
2. The point estimate of the log (relative risk) and standard errors obtained from Step 1 will 
be passed to PROC MIANALYZE to generate a combined result. The combined log 
(relative risk), relative risk and associated 95% CI and the resulting p-value will be 
reported. 
Supportive analyses for the primary estimand 
Additional supportive analyses will be conducted in addition to the primary and sensitivity 
analysis to provide additional insights into the understanding of the treatment effect. 
The primary analysis will be supported by a Cochran-Mantel-Haenszel test to evaluate the 
association between treatment and the primary outcome stratified by the randomization 
stratification variable (time from stroke onset to randomization ≤4.5 hours (yes/no). 
Homogeneity of the randomization stratification variable will be tested via Breslow-Day 
statistics. The common relative risk (nerinetide/placebo) over all strata with its 95% CI and p-
value will be reported. 
Example SAS code for the Cochran-Mantel-Haenszel test is as follows:  


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PROC FREQ DATA = ADMRS; 
TABLES RANDTIME*TRTP*CRIT1FL / CMH; 
RUN; 
A further supportive analysis will be an unadjusted two-sample comparison of binomial 
proportions via Wald test from logistic regression stratified on the randomization stratification 
factor (time from stroke onset to randomization ≤ 4.5 hours (yes/no)) to match the 
randomization. Estimated proportions (% responders) will be reported with binomial confidence 
intervals. 
Example SAS code for the logistic regression test is as follows: 
PROC LOGISTIC DATA = ADMRS; 
 
CLASS TRTP (PARAM=REF REF=’Placebo’); 
 
STRATA RANDTIME; 
 
MODEL CRIT1FL(EVENT=”Y”) = TRTP; 
 
ODDSRATIO TRTP / CL=WALD DIFF=ALL; 
RUN; 
Where CRIT1FL is the binary mRS responder status (yes/no). 
Two additionally supportive analyses to the primary analysis will be conducted: (1) the primary 
analysis reapplied to the Per Protocol population with observed cases (OC) only; (2) a re-
randomization analysis to demonstrate that minimization did not bias the primary endpoint 
analysis. The later test will consist of rerunning the randomization 5,000 times on the original 
subjects’ data and then performing the primary endpoint analysis on each of the re-randomized 
data sets. This will yield a distribution of 5,000 p-values that will correspond to the p-value 
distribution expected under the null hypothesis of no nerinetide effect. The p-value from the 
actual primary analysis will be compared to the distribution of randomization p-values. If (for 
example) the minimization was unbiased and actual p-value was 0.01, we would expect P=0.01 
to be near the 1st percentile of the distribution of the 5000 p-values. A variant of this 
methodology was successfully used to validate the minimization in the ESCAPE2 and 
ESCAPE-NA14 trials. 
Baseline, Day 6/Discharge, Day 30 and Day 90 mRS scores will be listed by treatment arm and 
subject. 
6.2 
Secondary Efficacy Estimand Analyses for Main Study 
The primary analysis for the secondary estimands with binary endpoints will be based on the ITT 
population following the same methods as the primary estimand, and reported as described for 
each estimand including reporting by randomization strata if the interaction term in the GLM 
used for the primary pivotal analysis plus the interaction term is significant at the 0.05 level. 
Missing data will be imputed according to Section 4.3. 
Binary secondary endpoints include: mortality rate, NIHSS responder and worsening of stroke.  
For the secondary estimand of the “mRS shift analysis”, the first step in the analysis will be an 
adjusted analysis with mRS score 5 and 6 combined, using a proportional odds model to derive 
the common odds of improvement (“shift”) along the mRS scale. The mRS shift analysis will 


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only be conducted provided that the proportional odds assumption is found to be valid on testing. 
If it is found to be invalid, the remaining secondary endpoints will be deemed to be protected. 
Adjustment will include the same variables as the primary outcome analysis. 
All tests will be conducted with two-sided level of significance alpha = 0.05 (overall for the in 
trial), adjusted for the interim analysis per the O’Brien-Fleming boundary spending function. A 
fixed sequence multiple testing procedure will control the overall experiment-wise error rate for 
the trial (see below). It pre-specifies that, with all tests conducted at the same pre-specified 
significance level, the primary endpoint will be tested first, and all subsequent tests are 
considered failed and deemed exploratory if conducted, in the order specified (primary analysis 
first, key secondary analysis second, etc.), after the first test which fails. All tests that follow the 
first failed test, are considered exploratory.  The secondary endpoints, and the order they are to 
be tested, are as they are listed in Table 1: Objectives and Endpoints. 
Sensitivity analysis of the secondary estimands will be conducted in ITT population with missing 
data not imputed.  
Additional analysis details of each outcome along with the supportive analyses of the secondary 
estimands are specified in each section below.  
6.2.1 Mortality  
Mortality rates, defined as the number of deaths observed divided by the number of participants 
observed over the 90-day study period between nerinetide and placebo control participants. 
Results will be summarized and tabulated.  
In addition to the primary and sensitivity analysis, mortality analysis will be additionally 
supported using: 
• Time-to-death survival function analysis, both unadjusted using Kaplan-Meier analysis and 
adjusted via Cox proportional hazards regression. Subjects who are known to be alive or 
the mortality status is unknown at study completion/discontinuation will be censored at the 
date of completion/discontinuation. 
• Unadjusted logistic regression as described for the primary estimand 
Mortality status scores will be listed by treatment arm and subject. 
6.2.2 Worsening of Stroke 
Worsening of Stroke is determined as the number of participants experiencing at least one 
worsening of stroke divided by the number of participants observed over the 90-day period in that 
treatment group, between nerinetide and placebo control participants.  Results will be summarized 
and tabulated. The unadjusted logistic regression method will be used as a supportive analysis. 
The alpha protected secondary analysis of Worsening of Stroke as currently designed will also be 
supported by a further analysis in which the imaging requirement is waived, in order to include in 
this supportive analysis any cases in which the stroke worsened so rapidly that the patient was 
deemed palliative early on and did not undergo further imaging. 
6.2.3 Secondary Outcome Analysis – mRS shift analysis 
The primary analysis of the ordinal mRS scores will employ a proportional odds model (POM) 
to test the hypothesis that, among randomized subjects, those who are treated with nerinetide will 
show a shift in their mRS score distribution at 90 days relative to the mRS distribution of the 


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placebo subjects. The magnitude of the shift will be estimated as the common odds ratio (95% 
CI). Modified Rankin scores of 5 and 6 (bed-bound with severe disability, and death) will be 
collapsed into a single category representing severely limited functioning. An adjusted POM will 
be used to derive the common odds of improvement (i.e. the nerinetide vs. placebo “shift” in 
mRS score distributions). Adjustment will include the same variables as the primary outcome 
analysis.  The mRS shift analysis will only be conducted provided that the proportional odds 
assumption is found to be valid on testing. Deceased participants will be included with a mRS 
score of 6.   
For the purpose of clarity, since the analysis of the ordinal mRS scores will employ a 
proportional odds model (POM), if test of the proportional odds assumption shows the 
assumption to be invalid, this key secondary analysis will not be performed and the remaining 
secondary outcomes will be deemed to be protected. 
Example SAS code for POM testing as follows: 
PROC LOGISTIC DATA=ADMRS; 
CLASS TRTP RANDTIME SEX BASPECT OCCLOC SITEGR1 / PARAM=GLM; 
MODEL AVAL = TRTP RANDTIME AGE SEX BNIHSS BASPECT OCCLOC 
IMA_TIME SITEGR1; 
EFFECTPLOT INTERACTION(X=TRTP SLICDBY=AVAL) / POLYBAR; 
ODDSRATIO TRTP / CL=WALD DIFF=ALL; 
RUN; 
Where “AVAL’ is the collapsed mRS scale values ranging from 0 to 5 (level 5 = 5+6 mRS 
combined). 
When SAS fits the POM, it runs a global test for a shift across all 6 mRS categories in the 
nerinetide group relative to the placebo; this is the test of the proportional odds (PO) assumption. 
The proportional odds assumption will be checked via the score test at an alpha-level of 0.15 and 
also using graphical methods to view the cumulative log odds for each mRS score. If the 
assumption holds, the POM estimates a single fixed odds ratio for the 5 cumulative binary 
endpoints defined as follows:  
1) The proportion of subjects with mRS = 0 vs. the proportion with mRS>0 
2) The proportion of subjects with mRS ≤ 1 vs. the proportion with mRS>1 
3) The proportion of subjects with mRS ≤2 vs. the proportion with mRS>2 
4) The proportion of subjects with mRS ≤3 vs. the proportion with mRS>3 
5) The proportion of subjects with mRS ≤4 vs. the proportion with mRS>4 
This means that regardless of how one chooses to dichotomize the mRS scale, the ratio of the 
odds of a nerinetide-treated subject’s being in the higher functioning category of the dichotomy 
to a control subject’s odds, will remain the same over the entire span of the mRS scale. Thus, 
there is no advantage to estimating ORs singly for any of the above dichotomies. If the PO 
assumption holds, none of them will be significantly different from the common odds ratio. This 
is analogous to the proportional hazard assumption of the Cox regression model, which posits a 
constant ratio of treatment vs. control hazard rates at every time point in a study. 


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Note that the model tests and estimates associated with endpoints “b” and “c” are the more 
commonly used (and less efficient) mRS dichotomies that represent “good” vs. “poor” 
functioning. Thus, in addition to providing a statistically powerful test for a treatment vs. placebo 
shift across all the mRS scores, the POM subsumes the more common dichotomous mRS 
analyses that efficacy decisions in stroke trials are often based on (Agresti 2007; Nunn 2016)16,17. 
The results of the PO assumption tests, the common odds ratio estimate (with Wald 95% CIs) 
and corresponding Wald test statistics will be summarized in a table. Actual proportions in each 
category of the collapsed mRS scale with corresponding stacked bar charts will also be 
presented. 
6.2.4 National Institutes of Health Stroke Scale 
The NIHSS scores will be dichotomized into 0-2 (indicating a good neurological outcome) 
versus >2 (indicating otherwise). The proportion of subjects achieving a good neurological 
outcome at Day 90 or the last rating after day 30 in nerinetide versus placebo control subjects 
will be summarized and tabulated. 
The same unadjusted logistic regression as discussed for the primary estimand will be used as a 
supportive analysis. 
Baseline, Post EVT, Day 5, Day 30 and Day 90 NIHSS scores will be listed by treatment arm 
and subject. 
6.3 
Tertiary Efficacy Outcomes Analyses for Main Study 
Summary statistics for each tertiary efficacy endpoint will be tabulated by treatment group. The 
tertiary analyses will be considered exploratory, and therefore are not subject to the fixed 
sequence multiple testing procedure to control the overall experiment-wise error rate for the trial 
as was done for the secondary analyses. These efficacy outcomes will be reported as described 
for each outcome including reporting by randomization strata if the interaction term in the GLM 
used for the primary pivotal analysis plus the interaction term is significant at the 0.05 level. 
The tertiary efficacy endpoints include the: 
• Volume of stroke as measured by MRI or CT brain imaging (MRI preferred).    
• Proportion of participants with functional independence in activities of daily living, as 
defined by a score of ≥ 95 on the Barthel Index (BI) at Day 90 post randomization. 
• Proportion of participants with reduced moderate or severe disability or death, as defined 
by a score of 4-6 on the mRS at Day 90 post randomization.  
• Proportion of participants with excellent functional outcome, as defined by a score of 0-1 
on the mRS at Day 90 post randomization.  
• Health-related quality of life, as measured by the EQ-5D-5L at Day 90. 
6.3.1 Volume of Stroke 
Total volume will be assessed using an adjusted analysis comprising of a linear regression that 
includes the stratification and minimization variables, and supported by an unadjusted two-tailed 
Student’s t-test. A cubic root transformation will be performed if needed. Results will be 
reported with confidence intervals for the unadjusted and adjusted treatment effect between 
treatment groups. 


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Stroke volume will be listed by treatment arm and subject. 
6.3.2 Barthel Index  
The BI scores will be dichotomized at 0-90 (indicating otherwise) versus 95-100 (indicating 
independent functioning with activities of daily living). The proportion of subjects with 
independent functioning with activities of daily living at Day 90 in nerinetide versus placebo 
control subjects will be analyzed using the same method as the primary analysis for the primary 
estimand. Results will be summarized and tabulated. 
Baseline, Day 30 and Day 90 BI scores will be listed by treatment arm and subject. 
6.3.3 Proportion of subjects with Day 90 mRS 4-6 
The Day 90 mRS score will be dichotomized at mRS ≥ 4 (indicating moderate, severe disability 
or death) vs. mRS < 4 (indicating otherwise). The proportion of subjects with based on this 
dichotomy on Day 90 in nerinetide versus placebo control subjects will be analyzed as the 
primary analysis described for the primary estimand. Results will be summarized and tabulated. 
6.3.4 Proportion of subjects with Day 90 mRS ≤ 1  
The Day 90 mRS score will be dichotomized at mRS≤1 (indicating freedom from disability) vs. 
mRS>1 (indicating otherwise). The proportion of subjects with freedom from 
dependence/disability based on this dichotomy on Day 90 in nerinetide versus placebo control 
subjects will be analyzed using the same method as the primary analysis for the primary 
estimand. Results will be summarized and tabulated. 
6.3.5 EQ-5D-5L 
For the EQ-5D-5L, the difference between nerinetide and placebo control subjects in the 
distribution of the EQ-VAS score at Day 90 will be summarized descriptively and modeled as a 
continuous variable. An analysis of covariance (ANCOVA) model will be fit to the EQ-VAS 
endpoint with the nerinetide/placebo treatment indicator variable and the stratification variables 
and covariates used in the supportive primary and secondary efficacy analyses. ANCOVA results 
will be summarized in a table. Least squared means, standard error and 95% CI will be reported. 
The five dimensions of EQ-5D-5L (Mobility, Self-Care, Usual Activities, Pain/Discomfort, and 
Anxiety/Depression) will be summarized using frequency counts and percentages separately by 
treatment group.  
Day 90 EQ-5D scores will listed by treatment arm and subject. 
6.4 
Exploratory Analyses for Main Study 
In addition to the primary, secondary and tertiary analyses supported by the described adjusted 
analyses, exploratory subgroup analyses will be conducted to determine whether any of these 
factors can modify the effect of the nerinetide vs. placebo treatments. Sub-group analyses will be 
performed on the primary estimand as well as the secondary estimands that are not considered 
exploratory following the fixed sequence multiple testing procedure described in Section 6.2. In 
addition, forest plots will be generated to display effect sizes by sub-group6. They will be 
reported by randomization strata if the interaction term in the primary pivotal analysis plus the 
interaction term is significant at the 0.05 level. 
Dichotomous sub-groups of interest include the following: 


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• Age (<80 years vs ≥ 80 years of age) 
• Age (<65 years vs ≥ 65 years of age) 
• Sex (men vs. women) 
• Ethnicity (Hispanics vs non-Hispanic) 
• Race (White, Asian, Black, Other) 
• Baseline stroke severity (NIHSS > Median vs. NIHSS <= Median) 
• Baseline occlusion location (MCA [including M1 and M2] vs. ICA) 
• Baseline ASPECT score (5-7 vs. 8-10) 
• Time from qualifying imaging to study drug initiation (greater than vs. less than the 
median). 
• Time from onset of stroke symptoms to start of study drug greater than vs. less than the 
median).  
• Degree of reperfusion (TICI ³ 2b vs. TICI <2b) 
• Subjects weighing between 105-120 kg. 
Additional sub-groups may be examined, but those specified above are of prior clinical interest.  
Effect sizes will be estimated as subgroup-specific odds ratios (±95% CIs) as follows. Separate 
logistic regression models for the primary/secondary endpoints, with treatment group and the 
stratification variables and covariates used in the minimization algorithm as predictors, will be fit 
to each of the subject subgroups (e.g., a model will be fit to males and a second model will be fit 
to females). The estimated (nerinetide/placebo) odds ratios, with 95% confidence intervals will 
be the nerinetide effect size estimates for each of the subgroups (e.g., for males and for females) 
and will be displayed in the forest plots.  
6.5 
Pharmacokinetic Analyses 
PK samples will be collected at baseline and at multiple time points after the complete dose was 
administered from up to 100 subjects enrolled at a subset of sites in Canada and the US.  
Actual sampling time-points will be recorded and used for PK calculations. If data permit, the 
following PK parameters for nerinetide will be calculated at the end of the study by standard 
noncompartmental methods for all subjects with PK samples: 
• AUC0–t: Area under the concentration-time curve from time zero to time of last 
measurable concentration 
• AUC0–inf: Area under the concentration-time curve from time zero to infinity 
• Cmax: Maximum plasma concentration observed after dosing 
• Tmax: Time to occurrence of Cmax 
• t½: Terminal elimination half-life 
Samples with no detectable nerinetide will be excluded from analysis (placebo).  
Descriptive statistics will be calculated for nerinetide plasma concentrations and for all PK 


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parameters (AUC0-t, AUC0-∞, Cmax, Tmax, t½). 
PK results at all timepoints will be listed for the Nerinetide arm by subject. 
6.6 
Outcome Analysis for 1-Year Sub-Study 
The outcomes of the 1-Year Sub-Study are intended to be supportive of the 90-day outcomes of 
the main study. The analysis population will be comprised of participants with a valid consent 
for the 1-year sub-study in the relevant jurisdiction. Missing data will be imputed as per Section 
4.3 except that for subjects who are successfully contacted (i.e., not deceased) but who cannot 
complete the telephone interview (e.g., due to dysphasia, a language barrier, or incapacity) will 
have their outcomes estimated by the interviewer. A summary table will specify the differences 
between the population analyzed in the main study and the 1-year sub-study, including deaths, 
losses to follow-up and withdrawal of consent.  
The primary outcome is the proportion of subjects with independent functioning on the modified 
Rankin Scale (mRS), as defined by a score of 0-2) at 1 year. 
The secondary outcomes include: 
• A reduction in mortality rate, as defined by event rate (%) for mortality over the 1-year 
study period. 
• The proportion of subjects with independent function on activities of daily living defined 
on the modified Barthel Index (BI) with a score of ≥ 95 at 1 year. 
• Health-related quality of life, as measured by the EQ-5D-5L at 1 year. 
6.6.1 mRS at 1 Year 
The mRS will be assessed as per the protocol. It will be dichotomized, analyzed and reported as 
in the primary efficacy analysis.  
6.6.2 Mortality Rate at 1 Year 
Mortality at 1 year will be assessed as per the protocol (from family or legally authorized 
representative or from hospital records). It will be analyzed and reported as described in Section 
6.2.1. 
6.6.3 Barthel Index at 1 Year 
The Barthel Index will be obtained as per the protocol from trial participants at 1 year. It will be 
dichotomized, analyzed and reported as for the primary analysis. 
6.6.4 EQ-5D-5L at 1 Year 
The EQ-5D-5L will be obtained by telephone or in-person interview from trial participants at 1 
year. EQ-5D-VAS will be analyzed and reported as described in Section 6.3.5. 
 


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Table 4: Summary of Inferential Efficacy Analyses 
Endpoint 
Primary Analysis* 
Sensitivity Analysis* 
Supportive Analysis* 
Primary 
Day-90 mRS 
Responder  
(≤2 vs. >2) 
Adjusted log-binomial 
regression model, ITT, SI  
Estimation of 
unconditional treatment 
effect will also be reported. 
- Adjusted log-binomial regression model, 
ITT, OC 
- Adjusted log-binomial regression model, 
ITT with Day 90 completers only (if 
missingness ≤ 5%) 
- Adjusted log-binomial regression model, 
ITT, MI (if missingness > 5%) 
- Adjusted log-binomial regression model, 
ITT, Tipping Point Analysis (if 
missingness > 5%) 
- Primary analysis with the interaction term 
added (treatment by randomization stratification 
factor) 
- Adjusted log-binomial regression model, ITT, 
Re-randomization 
- CMH, ITT, SI 
- Unadjusted logistic regression, ITT, SI 
- Adjusted log-binomial regression model, PP, 
OC 
Secondary 
Day-90 Mortality 
Adjusted log-binomial 
regression model, ITT 
Missing data imputed 
based on Day 30 status 
Adjusted log-binomial regression model, 
ITT, OC 
Mortality Rate: 
-  Unadjusted logistic regression, ITT, Missing 
data imputed based on Day 30 status 
- Adjusted log-binomial regression model, PP, 
OC 
Time to Death (Days): 
- Kaplan Meier, ITT, OC 
- Cox proportional hazard regression, ITT, OC 
Worsening of Stroke 
Adjusted log-binomial 
regression model, ITT, 
Missing data imputed 
based on Day 30 status 
Adjusted log-binomial regression model, 
ITT, OC 
- Unadjusted logistic regression, ITT, Missing 
data imputed based on Day 30 status 
-  Adjusted log-binomial regression model PP, 
OC 
Day-90 mRS shift 
(Ordinal) 
POM, ITT, SI 
- POM, ITT, OC 
- POM, ITT with Day 90 completers only 
POM, PP, OC 
Day-90 NIHSS 
Responder (≤2 vs. >2) 
Adjusted log-binomial 
regression model, ITT, 
LOCF 
Adjusted log-binomial regression model, 
ITT, OC 
- Unadjusted logistics regression, ITT, LOCF 
- Adjusted log-binomial regression model, PP, 
OC 
Tertiary  
Stroke volume 
Linear regression, ITT, OC 
N/A 
Student’s t-test, ITT, OC 
Day-90 Barthel 
Responder (<95 
vs.≥95) 
Adjusted log-binomial 
regression model, ITT, OC 
N/A 
N/A 
Day-90 mRS 
Adjusted log-binomial 
N/A 
N/A 


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Endpoint 
Primary Analysis* 
Sensitivity Analysis* 
Supportive Analysis* 
Responder (≤3 vs. ≥4) 
regression model, ITT, SI 
Day-90 mRS 
Responder (≤1 vs. >1) 
Adjusted log-binomial 
regression model, ITT, SI 
N/A 
N/A 
Day 90 EQ-VAS 
ANCOVA, ITT, OC 
N/A 
N/A 
1 Year 
mRS Responder (≤2 
vs. >2) 
Adjusted log-binomial 
regression model, ITT, MI 
N/A 
N/A 
Day-90 Mortality 
Adjusted log-binomial 
regression model, ITT, OC 
N/A 
N/A 
Barthel Index 
Adjusted log-binomial 
regression model, ITT 
N/A 
N/A 
EQ-VAS 
ANCOVA, ITT, OC 
N/A 
N/A 
*For analyses using the adjusted log-binomial regression model, a Poisson model with robust variance will be used if the log-binomial model fails to converge 


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SAFETY ANALYSES 
The safety population will consist of all subjects who received any dose of study drug. The main 
analyses will be frequency of SAEs and 90-day mortality. It is expected that the safety 
population and the ITT population will be near-identical.  
7.1 
Adverse Events 
Additional analyses will consider the frequency of AEs and discontinuations due to AEs. 
AEs will be collected until Day 30 and SAEs will be collected until Day 90 or the final contact. 
AEs will be summarized by presenting, for each treatment group, the number and percentage of 
subjects having at least one AE, having an AE in each body system and preferred term, by 
severity and relatedness to study medication. The frequencies and incidences of AEs occurring in 
subjects in the drug and placebo control groups will be summarized within treatment group by 
the Medical Dictionary for Regulatory Activities (MedDRA) System Organ Class (SOC). The 
frequencies and incidences of discontinuations due to AEs occurring in subjects in the nerinetide 
and placebo control groups will be summarized within treatment group. 
If a given subject had more than one AE mapped to the same preferred term, then that subject 
will be counted only once within that preferred term. 
A listing of Adverse Events of Special Interest (AESIs) can be found in Appendix 9.1 
When reporting TEAEs by maximum severity, if a given subject had more than one AE mapped 
to the same preferred term, then that AE will be counted once according to the maximal level of 
severity (Severe, Moderate, Mild). 
When reporting TEAEs by relationship to study treatment, if a given subject had more than one 
AE mapped to the same preferred term, then that AE will be counted once according to the 
highest level of relatedness (Related, Possibly, Unrelated). 
The following summaries (tables) of AEs and TEAEs will be provided by number (percentage) 
of subjects for each treatment group: 
• Overview of Adverse Events 
• TEAEs (with a start date 0-30 days) by MedDRA SOC and preferred term 
• Serious TEAEs (with start date 0-90 days) by MedDRA SOC and by preferred term 
• All TEAEs resulting in death by MedDRA SOC and by preferred term 
• Event rate (%) for Serious TEAEs over the 90-day study period between nerinetide and 
placebo control subjects will be compared by a logistic regression model similar to that of 
the primary analysis. 
• All TEAEs occurring in at least 5% of subjects in either treatment arm, by MedDRA SOC 
and by preferred term. 
• All TEAEs by maximum severity (Severe, Moderate, Mild) by MedDRA SOC and by 
preferred term.  Missing severity grades will be assumed as ‘severe’. 
• All TEAEs by relationship to study treatment (Related, Possibly, Unrelated) by MedDRA 
SOC and by preferred term.  Missing relationships will be assumed as ‘related’.  


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• Serious TEAEs (with start date 0-90 days) by relationship to study treatment (Related, 
Possibly, Unrelated) by MedDRA SOC and by preferred term.  Missing relationships will 
be assumed as ‘related’.  
• All TEAEs resulting in discontinuation of treatment, by MedDRA SOC and by preferred 
term 
• TEAESIs (onset 0-120 minutes post end of study drug infusion and of special interest as 
defined in Appendix 1: 
Listing of Treatment-Emergent AEs of Special Interest 
(TEAESI)) by MedDRA SOC and by preferred term 
The following listings of AE occurrences will be provided: 
• All AEs by MedDRA SOC and by preferred term 
• All SAEs by MedDRA SOC and by preferred term  
• All TEAEs leading to death by MedDRA SOC and by preferred term 
• All SAEs related to study drug by MedDRA SOC and by preferred term “Related” will 
include Related, Possibly and missing relationship 
• All TEAESIs by MedDRA SOC and by preferred term 
• All TEAEs resulting in discontinuation of treatment 
7.2 
Vital Signs 
A summary (table) of blood pressure (systolic and diastolic) will be reported at Baseline/Visit 1, 
immediately pre dose (Visit 1), post dose (Visit 1), Visit 2 (Post EVT) and at Visit 3 (Day 2/3). 
Absolute values and changes from Baseline (Visit 1) to post dose (Visit 1), Visit 2 (Post EVT) 
and at Visit 3 (Day 2/3) will be summarized descriptively.  
A summary (table) of heart rate will be reported at Baseline/Visit 1 (pre-dose), Visit 2 (Post 
EVT) and at Visit 3 (Day 2/3). Absolute values and changes from pre-dose to Post EVT and Day 
2 will be summarized descriptively.  
A summary (table) of temperature will be reported Baseline/Visit 1 (pre-dose), Visit 2 (Post 
EVT) and at Visit 3 (Day 2/3). Absolute values and changes from pre-dose to Post EVT and Day 
2 will be summarized descriptively.  
 A listing of all vital signs will be provided. 
7.3 
Laboratory Results 
A summary (table) of complete blood count (Platelets, hematocrit and hemoglobin), electrolytes 
(sodium, potassium and chloride) and chemistry (serum creatinine and serum glucose) will be 
reported at Baseline and Day 2. 
Absolute values and change from baseline values for laboratory results will be summarized 
descriptively. Inferential statistics (ie, p-values or CI) will not be provided for these data.  
A listing of all laboratory results as well as abnormal lab values post-dose will be provided. 
 


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7.4 
Concomitant Medications 
All concomitant medications collected on the Case Report Form with a start date prior to the date 
of Visit 4 (Visit will occur at Day 6 or hospital discharge if prior to Day 6) will be summarized 
by ATC Level 1 and Preferred Term within treatment group as well as listed in by-treatment by-
subject listings. 
 
 


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INTERIM ANALYSIS 
There will be an unblinded interim analysis and sample size re-estimation (SSRE) conducted in 
this trial when approximately 510 participants (75% information based on initial sample size) 
completed their 90-day study visit (that is when 510 participants have either completed Day 90 
visit or discontinued from the study prior to Day 90 visit).  
The interim analysis will be conducted by the unblinded statistician in the independent Statistical 
Group. An IDMC will review the interim efficacy and SSRE results. 
Depending on enrollment rates, it may be necessary to perform the interim analysis before 75% 
information to ensure sample size re-estimation is completed before the study has been fully 
enrolled. 
8.1 
Interim Efficacy Analysis 
There will be an interim efficacy analysis for unblinded sample size re-estimation in this trial. It 
will be conducted by the unblinded statistician in the Independent Statistical Group. 
The interim efficacy analysis will be performed after approximately 510 participants have 
complete the Day 90 follow-up, at 75% information on the primary endpoint. The interim 
efficacy analysis will be conducted on the ITT population, following the same methods as the 
study final analysis described in Table 5 below.  
Table 5: Summary of Interim Efficacy Analyses 
Endpoint 
Analysis 
Primary 
Day-90 mRS Responder  
(≤2 vs. >2) 
Adjusted log-binomial regression model, ITT, SI 
Secondary 
Day-90 Mortality 
 Adjusted log-binomial regression model, ITT 
Missing data imputed based on Day 30 status 
Worsening of Stroke 
Adjusted log-binomial regression model, ITT, Missing data 
imputed based on Day 30 status 
Day-90 mRS shift (Ordinal) 
POM, ITT, SI 
Day-90 NIHSS Responder 
(≤2 vs. >2) 
Adjusted log-binomial regression model, ITT, LOCF 
 
The planned initial sample size is of 680 evaluable participants randomized 1:1, allowing for a 
single interim analysis at 75% information (when about 510 patients have primary endpoint 
assessments) with O’Brien-Fleming alpha-spending function stopping boundary for 
overwhelming efficacy as well as the possibility of sample size re-estimation based on 
conditional power at the same interim look using the Chen-DeMets-Lan approach7 for unblinded 
sample size re-estimation. The trial-wise alpha (FWER) will be controlled at pivotal, 1-sided 
0.025 level via primary analysis using standard group sequential Wald test for comparison of 2 
independent proportions7,18 (EaST v6.5 2020), in spite of the sample size re-estimation, by the 
“promising zone” method using the Chen-DeMets-Lan approach1. The cumulative alpha spent at 
the interim analysis is 0.01 and final analysis 0.025, 1-sided; the stopping boundaries on the Z 
scale are 2.34 (interim) and 2.012 (final) and on the p-value scale 0.01 (interim) and 0.022 
(final), all on the assumption that the interim is conducted at 75% information (EaST v6.5, 
2020). If the interim analysis is conducted at a different time point other than when 75% 


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information available, the type I error and the efficacy boundary for the interim and final analysis 
will be adjusted accordingly using nQuery Advisor®.  
Power calculations for the unblinded sample size re-estimation design were run via simulation 
under the assumption of 2% probability of dropout during the trial (across both arms) using the 
Chen-DeMets-Lan approach1 for unblinded sample size re-estimation with a maximum sample 
size of 1020 randomized (sample size re-estimation inflation factor 1.5) and inflation based on 
conditional power promising zone between 50% and 80% based on the observed trend at the 
interim and using a Wald statistic (using a sample size increase rule to be specified in the IDMC 
Charter to prevent back-calculation of interim effect sizes).  
The IDMC may recommend stopping for overwhelming efficacy at the interim analysis if the test 
statistic crosses the O-F boundary.  Additionally, the IDMC may recommend a sample size 
modification for the trial per the pre-specified re-estimation criteria which are outlined in the 
IDMC Charter, based on the interim results provided by the Independent Reporting 
Statistician/Independent Statistical Center to the IDMC. However, notwithstanding the O-F 
superiority critical p-value of 0.01 for stopping (boundary value) at the interim analysis of the 
primary efficacy outcome, the IDMC will be instructed to make a recommendation on stopping 
per their own review of all data, and also, in support of their recommendation, to report to the 
Sponsor/Steering Committee whether or not the superiority boundary was crossed and how the 
study sample size should be adjusted after the interim analyses. The IDMC Charter will provide 
further details on the rationale for, and how, these recommendations will be communicated.   
The following summary tables and analyses will be performed at the interim analysis (also see 
Table 5) and provided to the IDMC in support of consideration of stopping for overwhelming 
efficacy at the interim analysis: 
• Subject disposition (e.g., number completed Day 90 visits) by treatment group  
• Subject demographics and baseline characteristics (as described in Section 5.5) by 
treatment group 
• Primary efficacy endpoint: 
o Proportion of participants with independent functioning on the modified Rankin 
Scale (mRS), as defined by a score of 0-2 (mRS responder) at Day 90  
• Secondary efficacy endpoints: 
o Mortality rate over the 90-day study period 
o Proportion of participants with worsening of stroke over the 90-day study period 
o Shift in mRS categories at Day 90 (mRS shift analysis) 
o Proportion of participants with a score of 0-2 on the NIHSS at Day 90  
By-subject data listings will also be provided to support the interim tables. 
The unblinded statistician in the Independent Statistical Group will also perform the conditional 
power calculation and sample size re-estimation by using nQuery Advisor® (Interim Monitoring 
and Unblinded Sample Size Re-estimation Module). The sample size increase rules will be 
provided to the unblinded statistician directly by the external regulatory statistician as per IDMC 
Charter, and will not be shared with any blinded study team members prior to database lock. The 
nQuery results, including the Wald test statistics and conditional power based on the treatment 


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effects at interim, boundary values per correct information time of interim analysis, sample size 
re-estimation rules, the re-estimated new sample size (if applicable) and the conditional power 
based on the new sample size will be provided to IDMC in a format (e.g. executive summary in a 
report or presentation slides) as deemed appropriate by the unblinded statistician.  
8.2 
Safety Analysis 
The Independent Statistical Group will generate safety reports, which will include cumulative 
summary statistics; subject status in the study (e.g., number completed Day 90 visits); baseline 
characteristics; safety data, including adverse events (AEs) and serious adverse events (SAEs) by 
AE code, and discontinuations due to AEs.  The IDMC may recommend stopping for safety at 
the interim analysis. 
The following safety summaries (tables) will be provided to the IDMC: 
• Overview of Adverse Events 
• TEAEs (with a start date 0-30 days) by MedDRA SOC and preferred term 
• Serious TEAEs (with start date 0-90 days) by MedDRA SOC and by preferred term 
• All TEAEs resulting in death by MedDRA SOC and by preferred term 
• All TEAEs resulting in discontinuation of treatment, by MedDRA SOC and by preferred 
term 
The following listings of AE occurrences will be provided: 
• All AEs by MedDRA SOC and by preferred term 
• All SAEs by MedDRA SOC and by preferred term 
• All AEs leading to death by MedDRA SOC and by preferred term 
8.3 
Independent Data Monitoring Committee 
Activities, mandate, responsibilities, communication structure and function of the IDMC will be 
documented in the IDMC Charter prospectively. This will also include a Blinding Plan 
specifying sequestering and blinding measures planned for the trial (including analysis firewalls) 
to prevent operational bias from revelation outside the IDMC of any aggregate interim results on 
safety or efficacy by treatment arm. 
Two versions of these safety reports will be created – an open (blinded) report to be distributed 
to the Trial Executive Committee and the IDMC, and a closed (unblinded) report to be 
distributed only to the IDMC. The closed reports will be forwarded to the Trial Executive 
Committee following database lock and unblinding at the end of the study. 
The IDMC will be unblinded to safety data to ensure a detailed analysis of safety. To ensure 
minimization of operational bias and confidentiality of the safety data, the IDMC reports will be 
analyzed by an unblinded group (the “Independent Statistical Center”) that is independent of the 
sponsor and the blinded project team who will implement the trial. Firewalls will be maintained 
between these two groups. No unblinded data reports will be seen or discussed by or with the 
blinded team during the trial.  The IDMC Charter (separate document) captures details of the 
firewalls. 


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The unblinded Independent Statistical Group will be sequestered from the Project Team, steering 
committee and investigators and will produce the IDMC Safety Reports as well as the Interim 
Analysis of Efficacy and provide them to the IDMC members. The reports to the IDMC will be 
provided prior to the meeting.  
The Independent Statistical Group is responsible to: 
• Prepare Tables, Figures and Listings for the IDMC to review 
• Prepare interim conditional power results and uSSR information for the IDMC to review 
(per nQuery, see Section 8.1above) 
• Apply the treatment codes to the data to produce the partially unblinded reports by 
treatment group (Group A vs Group B). 
• Perform a quality check of the results 
• Forward the agreed-upon Tables, Figures and Listings, conditional power results and uSSR 
information to the IDMC with an Interim Report (or presentation slides with executive 
summary) for the Interim uSSR  
The Global Coordinating Investigator will handle all blinded communication with the IDMC 
members. The IDMC Independent Reporting Statistician, also a member of the Independent 
Statistical Group, also attends the Open and Closed Sessions of the IDMC meetings and answers 
any questions from the IDMC regarding the reports.  The IDMC Chair will take minutes for the 
closed sessions. 
In contrast, the Project Statistician is on the blinded Project Team and will not produce, review or 
have access to unblinded aggregate reports for the IDMC during the study.  The Project 
Statistician’s group will produce the Final Study Report after final database lock and unblinding 
of the trial. 
8.4 
Handling of Enrollment Overage 
The interim analysis is anticipated to take place once 510 participants have reached their 90 day 
follow-up. The IDMC may recommend to (1) stop the trial due to overwhelming efficacy (2) to 
complete enrollment to the originally-planned 680 participants or (3) to increase the sample size 
based on the results of the sample-size re-estimation up to 1020 participants.  
It is possible that, by the time the IDMC provides a recommendation, enrollment in the study could 
exceed the number of participants needed to adhere to the IDMC recommendation. In such an 
eventuality, the primary outcome variable analysis for the main study and for the 1-Year Sub 
Study, as well as the Secondary Efficacy Estimand Analyses for the Main Study and for the 1-
Year Sub Study may also be performed on the participants as per the IDMC-recommended sample 
size as needed.  
 


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SUPPORTING DOCUMENTATION 
9.1 
Appendix 1: 
Listing of Treatment-Emergent AEs of Special Interest (TEAESI) 
Table A-1: AEs Related to Angioedema (by preferred term) based on SMQ 
• 
Allergic oedema 
• 
Angioedema 
• 
Circumoral oedema 
• 
Conjunctival oedema 
• 
Corneal oedema 
• 
Epiglottic oedema 
• 
Eye oedema 
• 
Eye swelling 
• 
Eyelid oedema 
• 
Face oedema 
• 
Gingival oedema 
• 
Gingival swelling 
• 
Idiopathic angioedema 
• 
Idiopathic urticaria 
• 
Laryngeal oedema 
• 
Laryngotracheal oedema 
• 
Limbal swelling 
• 
Lip oedema 
• 
Lip swelling 
• 
Mouth swelling 
• 
Oedema mouth 
• 
Oropharyngeal oedema 
• 
Oropharyngeal swelling 
• 
Palatal oedema 
• 
Palatal swelling 
• 
Periorbital oedema 
• 
Pharyngeal oedema 
• 
Scleral oedema 
• 
Swelling face 
• 
Swollen tongue 
• 
Tongue oedema 
• 
Tracheal oedema 
• 
Auricular swelling 
• 
Breast oedema 
• 
Breast swelling 
• 
Choking 
• 
Choking sensation 
• 
Drug hypersensitivity 
• 
Ear swelling 
• 
Endotracheal intubation 
• 
Generalised oedema 
• 
Hypersensitivity 
• 
Laryngeal obstruction 
• 
Localised oedema 
• 
Nasal oedema 
• 
Nipple oedema 
• 
Nipple swelling 
• 
Oedema 
• 
Oedema mucosal 
• 
Oedema peripheral 
• 
Orbital oedema 
• 
Peripheral swelling 
• 
Reversible airways obstruction 
• 
Skin oedema 
• 
Skin swelling 
• 
Stridor 
• 
Suffocation feeling 
• 
Throat tightness 
• 
Tracheal obstruction 
• 
Tracheostomy 
• 
Upper airway obstruction 
• 
Urticaria  
• 
Wheezing 
Table A-2: AEs related to Hypotension (by preferred term) based on MedDRA Terms 
• 
Blood pressure abnormal 
• 
Blood pressure decreased 
• 
Blood pressure diastolic abnormal 
• 
Blood pressure diastolic decreased 
• 
Blood pressure difference of extremities 
• 
Blood pressure fluctuation 
• 
Blood pressure immeasurable 
• 
Blood pressure inadequately controlled 
• 
Blood pressure orthostatic abnormal 
• 
Blood pressure orthostatic decreased 
• 
Blood pressure systolic abnormal 
• 
Blood pressure systolic decreased 
• 
Blood pressure systolic inspiratory decreased 
• 
Labile blood pressure 
• 
Hypotension 
• 
Diastolic hypotension 
• 
Hypotensive transfusion reaction 
• 
Orthostatic Hypotension 
 
 


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Table A-3: AEs related to Anaphylactic reaction and Anaphylactic shock (by preferred 
term) based on SMQs 
Anaphylactic reaction 
Anaphylactic shock 
• 
Anaphylactic reaction 
• 
Anaphylactic shock 
• 
Anaphylactic transfusion reaction 
• 
Anaphylactoid reaction 
• 
Anaphylactoid shock 
• 
Circulatory collapse 
• 
Distributive shock 
• 
Kounis syndrome 
• 
Shock 
• 
Shock symptom 
• 
Acute kidney injury 
• 
Acute respiratory failure 
• 
Asthma 
• 
Bronchial oedema 
• 
Bronchospasm 
• 
Cardio-respiratory distress 
• 
Dyspnoea 
• 
Erythema 
• 
Eye pruritus 
• 
Flushing 
• 
Generalised erythema 
• 
Hyperventilation 
• 
Hypoperfusion 
• 
Injection site urticaria 
• 
Jugular vein distension 
• 
Laryngospasm 
• 
Myocardial depression 
• 
Nodular rash 
• 
Ocular hyperaemia 
• 
Oropharyngeal spasm 
• 
Organ failure 
• 
Prerenal failure 
• 
Propofol infusion syndrome 
• 
Pruritus 
• 
Pruritus allergic 
• 
Pruritus generalised 
• 
Rash 
• 
Rash erythematous 
• 
Rash generalised 
• 
Rash pruritic 
• 
Renal failure 
• 
Respiratory arrest 
• 
Respiratory distress 
• 
Respiratory failure 
• 
Sensation of foreign body 
• 
Tachypnoea 
• 
Cardiac arrest 
• 
Cardio-respiratory arrest 
• 
Cardiovascular insufficiency 
 
 


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9.2 
Appendix 2: 
List of Abbreviations  
AE 
Adverse Event 
AESI 
Adverse Events of Special Interest 
AIS 
 
Acute Ischemic Stroke 
ANCOVA 
Analysis of Covariance 
ASPECTS 
Alberta Stroke Program Early Computerized Tomography Score 
ATC  
Anatomical Therapeutic Chemical 
AUC  
Area under the Curve 
BI 
 
Barthel Index 
BP 
 
Blood Pressure 
CT 
 
Computerized Tomography 
CTA  
Computerized Tomographic Angiography 
CTP 
 
Computerized Tomographic Perfusion 
DWI  
Diffusion Weighted Imaging 
eCOA  
electronic Clinical Outcome Assessment 
eMCAO 
Embolic Middle Cerebral Artery Occlusion 
EQ-5D-5L 
EuroQol 5-dimension 5-level (quality of life) 
EVT 
 
Endovascular Thrombectomy 
FLAIR  
Fluid Attenuated Inversion Recovery 
GRE  
Gradient Echo 
ICA   
Internal Carotid Artery  
IDMC  
Independent Data Monitoring Committee 
IND 
 
Investigational New Drug (USA) 
ITT 
 
Intent-to-Treat  
IV 
 
Intravenous 
LOCF  
Last Observation Carried Forward 
MedDRA 
Medical Dictionary for Regulatory Activities 
MCA   
Middle Cerebral Artery 
mCTA  
Multiphase Computerized Tomographic Angiography 
MR 
 
Magnetic Resonance  
MRI   
Magnetic Resonance Imaging 
MRP  
Magnetic Resonance Perfusion 
mRS  
Modified Rankin Scale 
NCCT  
Non-contrast Computed Tomography Scan 
NIHSS  
National Institutes of Health Stroke Scale 
OC 
 
Observed Cases 
O-F 
 
O’Brien-Fleming 
OR 
 
Odds Ratio 
PK 
 
Pharmacokinetic 
PO 
 
Proportional Odds 


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POM  
Proportional Odds Model 
PP 
 
Per Protocol 
PSD-95 
Post-Synaptic Density 95 
SAE 
 
Serious Adverse Event 
SAP 
 
Statistical Analysis Plan 
SI 
 
Single Imputation 
SOC  
System Organ Class 
SSRE  
Sample Size Re-Estimation 
TEAE  
Treatment-emergent Adverse Event 
TEAESI 
Treatment-emergent Adverse Events of Special Interest 
TICI 
 
Thrombolysis in Cerebral Infarction 
VAS  
Visual Analogue Scale 
wt 
 
Weight 
 


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