Clinical trial NCT07001852: EnDOvascular Therapy for Late WiNdow IschEmic Stroke Patients Selected bY AutoMatic Plain ComputErized Tomography
Official title: EnDOvascular Therapy for Late WiNdow IschEmic Stroke Patients Selected bY AutoMatic Plain ComputErized Tomography
Study type: INTERVENTIONAL
Overall status: NOT_YET_RECRUITING
Phase: NA
Conditions: Stroke Acute
Keywords: large vessel occlusion
Acute Ischemic Stroke
Lead sponsor: University of Iowa
Sponsor class: OTHER
Collaborators: name: Fundació Ictus
First posted: 2025-06-03
Enrollment: 500
Sex: ALL
Minimum age (years): 18
Maximum age (years): 80
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: The DONE SYMPLE Trial follows a parallel assignment model, in which eligible participants are randomly assigned in a 1:1 ratio to one of two study arms: (1) standard medical therapy alone (control group), or (2) standard medical therapy plus endovascular thrombectomy (intervention group). Participants remain in their assigned group for the duration of the study, and outcomes are assessed at predefined time points. This design allows for direct comparison between the intervention and control arms to evaluate the safety and efficacy of endovascular treatment initiated between 6 and 72 hours from last known well, based on selection by non-contrast CT analyzed with automated software.
Primary purpose: TREATMENT

Brief summary: The DONE SYMPLE Trial is a global clinical study testing whether a procedure called endovascular therapy, which removes blood clots from blocked brain arteries, can safely benefit more stroke patients when used up to 72 hours after symptoms begin. Endovacular Therapy is already proven to improve recovery in patients treated within 6 hours, but only when advanced imaging like Computed Tomography (CT) perfusion or Magnetic Resonance Imaging (MRI) is available to guide treatment. Unfortunately, many hospitals, specially in underserved areas, do not have access to this type of imaging.

This trial will investigate whether a basic brain scan called non-contrast CT, which is widely available in hospitals around the world, can be used instead. Special software will automatically analyze the CT scan to help doctors decide if a patient has enough brain tissue left to save with Endovascular Therapy. If this simpler approach works, it could expand access to lifesaving stroke care for more people globally.

The study will enroll 500 adult stroke patients, ages 18 to 80, with a large vessel blockage in the brain's anterior circulation, moderate to severe stroke symptoms, and who are between 6 and 72 hours from when they were last known to be well. All participants will undergo CT imaging analyzed by the automated software. If the scan shows a small core of already damaged brain tissue and a larger area of threatened but still viable brain, the patient will qualify.

Participants will be randomly assigned to receive either standard medical therapy alone or medical therapy plus Endovasculat Therapy which involves inserting a catheter through a blood vessel to reach the brain and using a device to remove the clot. This procedure is performed by trained stroke or neurointerventional specialists. The study is "open-label," meaning patients and doctors know which treatment is given, but the assessment of patient recovery will be done by independent reviewers who do not know the group assignments.

The primary goal is to determine if patients who receive Endovascular Therapy have better recovery at 90 days, measured by a scale called the modified Rankin Scale, which assesses how much disability a patient has after a stroke. The trial will also look at safety (especially brain bleeding after treatment), size and growth of brain injury on follow-up scans, recovery of strength and language, and overall quality of life and survival. Imaging will be reviewed centrally by a specialized team, and results will be analyzed to see how well Endovascular Therapy performs using this new patient selection method.

The DONE SYMPLE Trial is sponsored by the University of Iowa in collaboration with the University of Texas Health Science Center in Houston. It will take place at up to 20 hospitals worldwide. All patients will be followed closely with exams and imaging at specific time points up to 90 days after treatment.

If successful, this trial could change stroke care around the world by proving that Endovascular Therapy can be used safely and effectively even without advanced imaging, using tools available in most hospitals. This could help more stroke patients, especially in rural or resource-limited areas, access treatments that may improve their chances of recovery and reduce long-term disability.

Detailed description: The DONE SYMPLE Trial is a Phase III, multicenter, prospective, randomized, open-label trial with blinded endpoint assessment (PROBE design), evaluating the safety and efficacy of endovascular therapy (EVT) in patients with acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO) treated between 6 to 72 hours from last known well. The key innovation is the use of non-contrast computed tomography (NCCT) with automated software analysis as the sole selection modality, replacing advanced imaging requirements such as CT perfusion or MRI diffusion-perfusion mismatch.

The trial addresses critical gaps in access to reperfusion therapy by enabling stroke triage and selection using standard NCCT imaging combined with artificial intelligence tools, thereby facilitating inclusion of centers without advanced imaging infrastructure. The selection criteria are based on automated estimation of ischemic core volume (≤70 cc) and evidence of LVO detection, derived from FDA-cleared deep learning algorithms and structured image analysis (e.g., ASPECTS quantification and vessel segmentation).

A total of 500 patients will be randomized 1:1 to either (1) standard medical therapy or (2) EVT plus standard medical therapy. Randomization will be stratified by baseline stroke severity (NIH Stroke Scale), time from symptom onset, core infarct volume, and enrolling site. EVT will be performed using CE-marked or FDA-cleared thrombectomy devices following standard institutional practice.

The primary endpoint is global disability at 90 days, assessed using the utility-weighted modified Rankin Scale (dw-mRS). Secondary efficacy analyses include mRS ordinal shift, dichotomized mRS (0-2), NIHSS change, and angiographic endpoints such as reperfusion success (TICI ≥2b) and first-pass effect (TICI 2c-3 on first attempt). Safety outcomes include symptomatic intracranial hemorrhage (sICH) per Heidelberg criteria, infarct growth on serial imaging, and all-cause mortality.

The statistical framework employs a Bayesian Gaussian model stratified by time-to-treatment intervals (6-24, 24-48, and 48-72 hours). The adaptive enrichment design enables interim analyses after enrollment milestones (n=200, 275, 350, 425) to evaluate futility, efficacy, or harm. The final sample size accounts for 10% potential LVO detection misclassification by automated software and 5% anticipated loss to follow-up.

Imaging is adjudicated centrally by a blinded core laboratory, ensuring uniform quantification of infarct volume and recanalization metrics. Functional outcomes are assessed by trained evaluators blinded to treatment allocation. Trial conduct is overseen by an independent data monitoring committee and a clinical events committee to adjudicate adverse events and outcomes.

By leveraging accessible imaging with automated tools, the DONE SYMPLE Trial aims to demonstrate that safe and effective EVT can be extended to patients beyond 24 hours and in settings without advanced imaging. If positive, the findings will inform future guideline updates and support broader implementation of thrombectomy in underserved populations globally.

Eligibility criteria: Inclusion Criteria:

1. 18 to 80 years of age:

   1. Pre-stroke score (mRS) of 0-1 in participants aged 18 to 70 years.
   2. Pre-stroke Modified Rankin Scale (mRS) score of 0 in participants older than 70 years.
2. Presenting with signs and symptoms consistent with an acute ischemic stroke within 24-72 hours from last known well. \*
3. Baseline NIHSS ≥8.
4. NCCT imaging indicating the existence of an anterior circulation LVO by an automated software, or CTA (when available).
5. Core volume ≤ 70 cc determined by a deep learning algorithm in automated software and/or ASPECTS scoring ≥ 6. \*\*
6. Arterial puncture within 72 hours (after the first symptoms or LKW).
7. Arterial puncture within 90 minutes from initial CT.
8. Ability to randomize within 72 hours after stroke onset (last seen well).
9. Ability to obtain signed informed consent or subject's Legally Authorized representative (LAR) has signed Consent form \*\*\*

   * Patients in the 6-24-hour after Last Known Well (LKW) may be enrolled only in centers where thrombectomy is not offered as standard of care due to the absence of advanced imaging capabilities.

     * In cases of discrepancy between the automated tool LVO detection and volume, and ASPECT Score or CTA judgment or Computed Tomography Angiography CTA findings, ASPECTS and CTA will take precedence.

       * If approved by local ethics committee and country regulations, the investigator is allowed to enroll a patient utilizing emergency informed consent procedures if neither the patient nor the representative or person of trust is available to sign the informed consent form. However, as soon as possible, the patient is informed, and his/her consent is requested for the possible continuation of this research.

Exclusion Criteria:

1. Females who are pregnant, or those of child-bearing potential with positive urine or serum beta Human Chorionic Gonadotropin (HCG) test.
2. Known severe allergy (more than a rash) to contrast media uncontrolled by medications.
3. Refractory hypertension (defined as persistent systolic blood pressure \>185 mmHg or diastolic blood pressure \>110 mmHg) despite medication.
4. CT evidence of the following conditions:

   * Midline shift or herniation.
   * Evidence of intracranial hemorrhage.
   * Mass effect with effacement of the ventricles.
5. Bilateral strokes.
6. Clot retrieval previously attempted \<6 hours.
7. Treated with thrombolytics \>4.5 hours after last seen well.
8. Intracranial tumors.
9. Life expectancy less than 90 days prior to stroke onset.
10. Participation in another randomized clinical trial that could confound the evaluation of the study.
11. Presumed septic embolus, or suspicion of bacterial endocarditis.
12. Pre-existing neurological or psychiatric disease that would confound the neurological or functional evaluations, e.g. dementia with prescribed anti-cholinesterase inhibitor (e.g. Aricept).
13. Any other condition (in the opinion of the site investigator) that precludes an endovascular procedure or poses a significant hazard to the patient if an endovascular procedure was performed.

Primary outcomes:
measure: Global Disability at 90 Days
timeFrame: 90 days (±14 days)
Secondary outcomes:
measure: Ordinal Distribution of the Modified Rankin Scale (mRS) at 90 Days
timeFrame: 90 days (±14 days)
measure: Proportion of Participants with Functional Independence (mRS 0-2) at 90 Days
timeFrame: 90 days (±14 days)
measure: Change in NIH Stroke Scale (NIHSS) Score at 24 Hours
timeFrame: 24 hours (±16 hours)
measure: Change in NIHSS Score at Day 5 or Discharge
timeFrame: 5 days (±1 day) or at discharge
measure: Major Early Neurological Improvement at 24 Hours
timeFrame: 24 hours (±16 hours)
measure: Early Neurological Recovery at 24 Hours
timeFrame: 24 hours (±16 hours)
measure: Successful Angiographic Reperfusion
timeFrame: At the end of the endovascular procedure
measure: First Pass Recanalization Rate
timeFrame: Perioperative/Periprocedural
measure: Workflow Efficiency Metrics
timeFrame: From hospital arrival to procedure completion
measure: Length of Inpatient Stay
timeFrame: From hospital admission to discharge (up to 90 days post-randomization)
measure: Discharge Disposition
timeFrame: At hospital discharge (up to 90 days post-randomization)
measure: Health-Related Quality of Life (HRQoL) at 90 Days
timeFrame: 90 days (±14 days)
Other outcomes:
Locations:
city: Iowa City
country: United States
facility: University of Iowa
state: Iowa
Study officials:
affiliation: Cooper University Health Care
name: Tudor Jovin, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Hospital Vall d"Hebron Barcelona
name: Marc Ribo, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Jovin TG, Nogueira RG, Lansberg MG, Demchuk AM, Martins SO, Mocco J, Ribo M, Jadhav AP, Ortega-Gutierrez S, Hill MD, Lima FO, Haussen DC, Brown S, Goyal M, Siddiqui AH, Heit JJ, Menon BK, Kemp S, Budzik R, Urra X, Marks MP, Costalat V, Liebeskind DS, Albers GW. Thrombectomy for anterior circulation stroke beyond 6 h from time last known well (AURORA): a systematic review and individual patient data meta-analysis. Lancet. 2022 Jan 15;399(10321):249-258. doi: 10.1016/S0140-6736(21)01341-6. Epub 2021 Nov 11.
citation: Desai SM, Haussen DC, Aghaebrahim A, Al-Bayati AR, Santos R, Nogueira RG, Jovin TG, Jadhav AP. Thrombectomy 24 hours after stroke: beyond DAWN. J Neurointerv Surg. 2018 Nov;10(11):1039-1042. doi: 10.1136/neurintsurg-2018-013923. Epub 2018 May 28.
citation: Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, Yavagal DR, Ribo M, Cognard C, Hanel RA, Sila CA, Hassan AE, Millan M, Levy EI, Mitchell P, Chen M, English JD, Shah QA, Silver FL, Pereira VM, Mehta BP, Baxter BW, Abraham MG, Cardona P, Veznedaroglu E, Hellinger FR, Feng L, Kirmani JF, Lopes DK, Jankowitz BT, Frankel MR, Costalat V, Vora NA, Yoo AJ, Malik AM, Furlan AJ, Rubiera M, Aghaebrahim A, Olivot JM, Tekle WG, Shields R, Graves T, Lewis RJ, Smith WS, Liebeskind DS, Saver JL, Jovin TG; DAWN Trial Investigators. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. N Engl J Med. 2018 Jan 4;378(1):11-21. doi: 10.1056/NEJMoa1706442. Epub 2017 Nov 11.
citation: Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, San Roman L, Serena J, Abilleira S, Ribo M, Millan M, Urra X, Cardona P, Lopez-Cancio E, Tomasello A, Castano C, Blasco J, Aja L, Dorado L, Quesada H, Rubiera M, Hernandez-Perez M, Goyal M, Demchuk AM, von Kummer R, Gallofre M, Davalos A; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med. 2015 Jun 11;372(24):2296-306. doi: 10.1056/NEJMoa1503780. Epub 2015 Apr 17.