Intraventricular Fibrinolysis for Aneurysmal Subarachnoid Hemorrhage.

Study Overview
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Brief Summary
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Aneurysmal subarachnoid hemorrhage (SAH) is a devastating form of stroke, with delayed cerebral ischemia (DCI) as a major complication. There are several evidences, both in preclinical and in clinical studies that intraventricular fibrinolysis (IVF) controls the phenomenon that are leading to DCI. Here, the investigators propose to conduct a phase III trial to provide a clear evaluation of the impact of IVF after aneurysmal SAH.

Detailed Description
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Introduction: Aneurysmal subarachnoid hemorrhage (SAH) is a devastating form of stroke, which often causes acute hydrocephalus requiring the insertion of an external ventricular drain (EVD). A major complication of aneurysmal SAH is delayed cerebral ischemia (DCI), which corresponds to the occurrence of an ischemic stroke up to 21 days after the aneurysm rupture. There are currently only few ways to prevent it. As DCI is linked to the presence of blood within the subarachnoid space, it has been hypothesized that removing this blood may decrease the risk of DCI. It could be obtained by injecting a fibrinolytic agent through the EVD, a therapeutic strategy named intraventricular fibrinolysis (IVF). There are several evidences, both in preclinical and in clinical studies that IVF controls the phenomenon that are leading to DCI. It has notably been shown in Phase I and Phase II trial that IVF in aneurysmal SAH is safe and may decrease the risk of DCI, with a trend to improve the rate of good functional outcome by about 10%. Here, the investigators propose to conduct a phase III trial to provide a clear evaluation of the impact of IVF after aneurysmal SAH. Materials and methods: this study will include patients with aneurysmal SAH requiring external ventricular drainage. The investigators will perform a pragmatic randomized controlled trial: compare the standard of care, i.e. the EVD alone, to the experimental treatment, i.e. IVF, with an open design. After exclusion of the aneurysm, patients will be randomly allocated to receive either EVD alone or EVD+IVF (72 hours, 9 doses). The primary outcome will be the proportion of patients without severe disability 6 months after the aneurysm rupture, as evaluated by the modified Rankin Scale (mRS). The investigators plan to include 440 patients, to show an increase of the rate of good functional outcome of 10% in the EVD+IVF group compared to the EVD alone group (α=0.05 and β=0.8). To obtain such sample, a multicenter trial is mandatory, and to date 16 centers accepted to participate. Each center will include one patient per month, and the inclusion period is to last 48 months.

Official Title
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Intraventricular Fibrinolysis Versus External Ventricular Drainage Alone in Aneurysmal Subarachnoid Hemorrhage: a Randomized Controlled Trial.

Conditions
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Subarachnoid Hemorrhage

Intervention / Treatment
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* Drug: EVD + IVF with Alteplase


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients (age 18-75) with SAH on initial CT-Scan examination. SAH associated with hydrocephalus requiring external ventricular drainage. Confirmation of an associated intracranial aneurysm by vascular imaging. Time from onset to admission under 24 hours. Exclusion of the aneurysm by surgical clipping or endovascular coiling before IVF. Oral information on research and informed consent of the patient and/or his relatives. Exclusion Criteria: Patient with severe clinical presentation on admission: WFNS score = 5. Associated intracerebral hematoma of more than 2 cm in its larger width. SAH diagnosed on lumbar puncture: original Fisher grade = 1. Impossibility to exclude the aneurysm within 72 hours following its rupture. Patient previously treated with antiplatelet therapy or treated with antiplatelet therapy after the aneurysm exclusion. Severe coagulopathy, including oral vitamin K antagonist. Pregnant or lactating woman.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 75 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: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: We plan to perform a pragmatic randomized controlled trial: compare the standard of care, i.e. the EVD alone, to the experimental treatment, i.e. IVF. As the standard treatment does not include injection within the EVD, the trial will not include injection through the EVD in the control group, so the trial will have an open design.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: EVD alone<br>In the EVD alone group group, the EVD will be managed as usual - i.e. will only be used to drain CSF. | |
| Experimental: EVD + IVF with Alteplase<br>Intraventricular fibrinolysis: Injection through the EVD of 1mg in 1 mL of Alteplase every eight hours during 3 days (9 doses). | Drug: EVD + IVF with Alteplase<br>* Intraventricular fibrinolysis: Injection through the EVD of 1mg in 1 mL of Alteplase every eight hours during 3 days (9 doses).<br>* Other names: Intraventricular fibrinolysis with Alteplase;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Participants With Modified Rankin Scale (mRS) <=3 - Dichotomized Analysis. | Proportion of patients without severe disability evaluated by the modified Rankin Scale (0-3). The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. It is scored from 0 (perfect health without symptoms) to 6 (death). | 6 months. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Death | Risk of death | 6 months | 
| DCI. | The presence of cerebral infarction on CT or MR scan on the latest CT or MR scan made before death within 6 weeks, not present on the CT or MR scan between 24 and 48 hours after early aneurysm occlusion, and not attributable to other causes such as surgical clipping or endovascular treatment. | 6 weeks | 
| Clinical deterioration caused by DCI. | Occurrence of focal neurological impairment (such as hemiparesis, aphasia, apraxia, hemianopia, or neglect), or a decrease of at least 2 points on the Glasgow Coma Scale. This should last for at least 1 hour, is not apparent immediately after aneurysm occlusion, and cannot be attributed to other causes by means of clinical assessment, CT or MRI scanning of the brain, and appropriate laboratory studies | 1 month | 
| EVD obstruction. | Numbers of permanent catheter obstruction requiring the insertion of a new catheter. | 1 month | 
| Internal CSF shunt surgery. | Rate of internal CSF shunt surgery. | 3 months | 
| Rebleeding. | A new ICH identified on a CT-scan performed after IVF that was not present before IVF. | 4 days | 
| Catheter related infection. | Clinical picture of infection associated with a positive CSF culture. | 3 month | 
| Rate of patients who returned to work. | Proportion of patient who returned to their previous professional activity. | 6 months | 
| Quality of life evaluated by the MOS SF-36 scale | MOS SF-36 scale | 6 months | 
| Asthenia. | Asthenia scale of Pichot | 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Subarachnoid Hemorrhage, Intracranial Aneurysm, Cerebral Ischemia, Ventriculostomy, Tissue Plasminogen Activator