The Intra-arterial Vasospasm Trial

Study Overview
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Brief Summary
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The primary objective of the study is to determine the optimal intra-arterial drug treatment regimen for arterial lumen restoration post cerebral vasospasm following aneurysmal subarachnoid hemorrhage. The secondary objective is to evaluate clinical outcome at 90 days post discharge following optimal intra-arterial drug treatment for cerebral vasospasm. We hypothesize that Intra-arterial (IA) infusion of a combination of multiple vasodilators is more efficacious than single agent treatment cerebral vasospasm therapy. All procedures done as a part of this study are standard hospital care procedures done to treat cerebral vasospasm and all drugs to be used are FDA approved.

Detailed Description
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The primary objective of the study is to determine the optimal intra-arterial drug treatment regimen for arterial lumen restoration post cerebral vasospasm following aneurysmal subarachnoid hemorrhage. The secondary objective is to evaluate clinical outcome at 90 days post discharge following optimal intra-arterial drug treatment for cerebral vasospasm. This study is a prospective multicenter randomized trial. The primary outcome measure is the Post infusion improvement ratio (PIIR) assessed 10 minutes after completion of the intra-arterial infusion. PIIR is a measure of arterial lumen diameter pre and post intra-arterial drug infusion in the presenting vasospasmic blood vessel. Modified Rankin score (mRS) at 3 months post hospital discharge will be recorded as a secondary outcome to assess clinical outcome. The interventions in this study are a part of routine standard of care (SOC) procedures for cerebral vasospasm treatment. Following surgical or endovascular intervention for aneurysmal Subarachnoid Hemorrhage (aSAH) if patients develop cerebral vasospasm refractory to maximal medical management, endovascular treatment by intra-arterial drug infusion of single drug agent or cocktail drug agents will be initiated. Study participants will be randomly assigned to one of the three treatment groups where one single drug agent or cocktail drug agents will be intra-arterially administered. Pre & post infusion vasospasmic vessel diameters will be compared. The change in diameter will be quantified based on the mean percentage change. Three months post hospital discharge, study participants will be followed up in clinic to evaluate clinical outcome. The study will require 330 patients in total. The patient population will be hospitalized patients presenting with cerebral vasospasm post aneurysmal subarachnoid hemorrhage. Subjects will be stratified by randomization into 3 treatment groups.

Official Title
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The Intra-arterial Vasospasm Trial(iVAST)- A Multi-center Randomized Study

Conditions
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Cerebral Vasospasm

Intervention / Treatment
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* Drug: Nicardipine
* Drug: Verapamil
* Drug: Nicardipine + Verapamil + Nitroglycerin


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adult patient, age 18-80 years old, with ruptured aneurysm(s) who experience cerebral vasospasm post operatively within 3-21 days. Symptomatic vasospasm (clinical or TCD) For centers that perform a routine day 7 angiogram post-aneurysm treatment - 50% or more stenosis seen on diagnostic angiogram for asymptomatic patients. Exclusion Criteria: Inability to obtain consent from patient or patients kin Pregnant women less than 18 years of age of more than 80 years of age Hunt Hess Grade 5 SAH Intra-arterial drug treatment in all 3 arterial territories

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Nicardipine<br>Group 1 : Nicardipine 5mg per circulation intra-arterial injection, Pharmacological angioplasty | Drug: Nicardipine<br>* Pharmacological angioplasty: intra-arterial drug infusion via catheter to treat cerebral vasospasm<br>* Other names: Cardene;|
| Active Comparator: Verapamil<br>Group 3: Verapamil 10mg per circulation intra-arterial injection, Pharmacological angioplasty | Drug: Verapamil<br>* Pharmacological angioplasty: intra-arterial drug infusion via catheter to treat cerebral vasospasm<br>|
| Active Comparator: Nicardipine + Verapamil + Nitroglycerin<br>Group 4 : Nicardipine 5mg + Verapamil 10mg + Nitroglycerin 200mcg in 4cc 5 % dextrose in water , intra-arterial injection, Pharmacological angioplasty | Drug: Nicardipine + Verapamil + Nitroglycerin<br>* Pharmacological angioplasty: intra-arterial drug infusion via catheter to treat cerebral vasospasm<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Post infusion improvement ratio(PIIR) | Post infusion improvement ratio(PIIR) = (B - A) / A A = pre-infusion blood vessel diameter B = post infusion blood vessel diameter PIIR across all four treatment arms will be compared and tested for statistical significance. | pre pharmacological angioplasty blood vessel diameter - 0 min, post pharmacological angioplasty blood vessel diameter- 10 min after infusion | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| To grade clinical outcome using Modified Rankin score | Clinical outcome at 3 months post discharge from hospital after treatment will be evaluated using Modified Rankin score | 3 months post discharge from hospital | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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cerebral vasospasm, aneurysmal subarachnoid hemorrhage, intra arterial drug treatment for cerebral vasospasm, nicardipine milrinone nitroglycerin verapamil