Conditions: Stroke, Acute
Keywords: Acute Ischemic Stroke Endovascular Thrombectomy Neuroprotection Tat-NR2B9c NA-1 Nerinetide
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 1105
Healthy volunteers: no

Brief summary:
The ESCAPE-NA-1 study is designed to determine the safety and efficacy of the neuroprotectant, Nerinetide (NA-1), in reducing global disability in subjects with major acute ischemic stroke (AIS) with a small established infarct core and with good collateral circulation who are selected for endovascular revascularization.

Detailed description:
Trial Objectives:

The primary objective is to determine the efficacy of the neuroprotectant, Nerinetide, in reducing global disability in subjects with major acute ischemic stroke (AIS) with a small established infarct core and with good collateral circulation selected for rapid endovascular revascularization.

The secondary objectives are to determine the efficacy of Nerinetide in:

* Reducing functional dependence
* Improving neurological outcome
* Improving activities of daily living
* Reducing mortality rate The leading 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 (IV) infusion of Nerinetide to subject with acute stroke who are selected for endovascular revascularization on serious adverse events (SAEs) and 90-day mortality.

Trial Design:

This study is a Phase 3, randomized, multicentre, blinded, placebo-controlled, parallel group, single-dose design. Subjects harboring an acute ischemic stroke and who are selected for endovascular revascularization in accordance with local institutional practices and who harbor a small established infarct core and with good collateral circulation will be given a single, 2.6 mg/kg (up to a maximum dose of 270 mg) intravenous dose of Nerinetide (NA-1) or placebo as soon as they are deemed to have met the enrollment criteria and with the intention of starting administration within 30 minutes of randomization. The randomization will be by stochastic minimization to balance baseline factors.

Arms:
arm 1: Drug vehicle only arm 2: None

Interventions: intervention 1: Nerinetide (NA-1), 2.6 mg/kg intervention 2: Placebo
Intervention descriptions: intervention 1: Single intravenous infusion of nerinetide over 10 ± 1 minutes intervention 2: Placebo Comparator: Placebo

Protocol document:
Prot_000.pdf: 
NoNO Inc.  
Protocol NA-1-007 
Date:  19 February 2019 
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Coordinating Centre 
University of Calgary 
Foothills Medical Center 
1403 29th Street NW 
Calgary, AB T2N 2T9 
Sponsor 
NoNO Inc.  
Krembil Research Institute 
8KD-406, 60 Leonard Avenue 
Toronto, ON Canada M5T 2S8 
A Multicentre, Randomized, Double-blinded, Placebo-controlled, Parallel Group, Single-
dose Design to Determine the Efficacy and Safety of Intravenous NA-1 in Subjects with 
Acute Ischemic Stroke Undergoing Endovascular Thrombectomy (ESCAPE-NA1 Trial) 
PROTOCOL NA-1-007, Version 9.0  
(AMENDMENT #8) 
ISSUE DATE: 19th February 2019 
Health Authority File Number: 
EudraCT number 2016-001826-33 
clinicaltrials.gov number NCT02930018 




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Table of Contents 
1 GENERAL INFORMATION ................................................................................................ 2 
1.1 SIGNATURES OF APPROVAL ............................................................................................................... 2 
1.2 LIST OF ABBREVIATIONS.................................................................................................................... 8 
2 STUDY SYNOPSIS ............................................................................................................... 11 
3 COORDINATING CENTRE, SPONSOR, INVESTIGATORS AND FACILITIES ..... 18 
4 BACKGROUND INFORMATION ..................................................................................... 20 
4.1 RATIONALE ....................................................................................................................................... 20 
4.2 THE NEUROPROTECTANT, NA-1 ..................................................................................................... 20 
4.3 SUMMARY FROM NONCLINICAL STUDIES AND CLINICAL TRIALS ................................................ 21 
4.3.1 
NONCLINICAL STUDIES 
22 
4.3.2 
CLINICAL TRIALS 
25 
4.4 SUMMARY OF KNOWN POTENTIAL RISKS AND BENEFITS ............................................................. 27 
4.4.1 
PHASE 1 STUDY 
27 
4.4.2 
PHASE 2 STUDY (ENACT) 
27 
4.4.3 
SUMMARY OF SAFETY OF NA-1 
28 
4.5 DESCRIPTION OF AND JUSTIFICATION FOR THE ROUTE OF ADMINISTRATION, DOSAGE, DOSAGE 
REGIMEN AND TREATMENT PERIOD ........................................................................................................ 28 
4.6 TARGET PATIENT SELECTION ......................................................................................................... 28 
4.7 ENDOVASCULAR ACUTE STROKE THERAPY ................................................................................... 29 
4.8 IMAGING AS A BIOMARKER FOR PATIENT SELECTION .................................................................. 30 
5 TRIAL OBJECTIVES .......................................................................................................... 32 
5.1 PRIMARY OBJECTIVE ....................................................................................................................... 32 
5.2 SECONDARY OBJECTIVES ................................................................................................................ 32 
5.3 TERTIARY OBJECTIVES .................................................................................................................... 32 
5.4 LEADING SAFETY OBJECTIVES ........................................................................................................ 32 
6 TRIAL DESIGN .................................................................................................................... 33 
6.1 OUTCOMES ........................................................................................................................................ 33 
6.1.1 
PRIMARY EFFICACY OUTCOME 
33 
6.1.2 
SECONDARY EFFICACY OUTCOMES 
33 
6.1.3 
TERTIARY OUTCOMES 
33 
6.1.4 
SAFETY OUTCOMES OF SPECIAL INTEREST 
34 
6.2 RANDOMIZATION AND BLINDING .................................................................................................... 35 
6.3 PROCEDURE FOR BREAKING THE RANDOMIZATION CODE ........................................................... 36 
6.4 TREATMENT ...................................................................................................................................... 37 
6.4.1 
DOSAGE FORM, ACCOUNTABILITY AND LABELING 
37 
6.4.2 
DISPOSITION OF STUDY DRUG SUPPLIES 
37 
6.5 STUDY DRUG MONITORING ............................................................................................................. 38 
6.6 CASE REPORT FORMS ...................................................................................................................... 38 
6.7 PROCESS, TIMING AND QUALITY ASSURANCE METRICS ............................................................... 38 
7 SELECTION AND WITHDRAWAL OF SUBJECTS ..................................................... 39 
7.1 STUDY ENROLMENT PROCESS ......................................................................................................... 39 
7.2 INCLUSION CRITERIA ....................................................................................................................... 39 


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7.3 EXCLUSION CRITERIA ...................................................................................................................... 40 
8 TREATMENT OF SUBJECTS ........................................................................................... 42 
8.1 STUDY INTERVENTIONS .................................................................................................................... 42 
8.1.1 
ADMINISTRATION OF STUDY DRUG 
42 
8.2 INTERVENTIONS ................................................................................................................................ 43 
8.2.1 
ENDOVASCULAR INTERVENTION 
43 
8.3 GUIDELINES-BASED MEDICAL/STROKE UNIT CARE ...................................................................... 43 
8.4 SPEED OF INTERVENTION ................................................................................................................. 45 
8.5 CONSENT PROCESS ........................................................................................................................... 45 
8.6 BASELINE CLINICAL AND LABORATORY EVALUATIONS ............................................................... 46 
8.7 IMMUNOGENICITY SUBSTUDY ......................................................................................................... 46 
8.7.1 
IMMUNOGENICITY SAMPLE COLLECTION 
46 
8.7.2 
IMMUNOGENICITY SAMPLE STORAGE AND SHIPMENT 
47 
8.8 PHARMACOKINETICS SUBSTUDY ..................................................................................................... 47 
8.8.1 
PK SAMPLE COLLECTION 
47 
8.8.2 
PK SAMPLE STORAGE AND SHIPMENT 
47 
8.9 BRAIN AND NEUROVASCULAR IMAGING ......................................................................................... 48 
8.10 STUDY DRUG ADMINISTRATION .................................................................................................... 48 
8.11 EVALUATIONS FOLLOWING RANDOMIZATION ............................................................................ 48 
8.12 IMAGING .......................................................................................................................................... 49 
8.13 CRITERIA FOR DISCONTINUATION FROM THE STUDY ................................................................. 49 
9 ASSESSMENT OF EFFICACY .......................................................................................... 50 
9.1 THE MODIFIED RANKIN SCALE ....................................................................................................... 50 
9.2 THE NATIONAL INSTITUTES OF HEALTH STROKE SCALE ............................................................. 50 
9.3 BARTHEL INDEX ............................................................................................................................... 50 
9.4 MORTALITY RATE ............................................................................................................................ 50 
9.5 EQ-5D-5L.......................................................................................................................................... 50 
9.6 VOLUME OF STROKES ...................................................................................................................... 51 
9.7 COGNITIVE OUTCOMES.................................................................................................................... 51 
9.8 PHARMACOKINETICS ASSESSMENT ................................................................................................. 51 
9.9 ADDITIONAL ASSESSMENTS ............................................................................................................. 51 
10 ASSESSMENT OF SAFETY ............................................................................................. 53 
10.1 ADVERSE EVENT DEFINITIONS ...................................................................................................... 53 
10.2 CLINICAL MANAGEMENT OF ADVERSE EVENTS .......................................................................... 55 
10.2.1 EARLY STUDY DRUG CESSATION 
55 
10.2.2 TREATMENT OF HYPOTENSION 
55 
10.2.3 INCREASES IN HISTAMINE 
56 
10.2.4 HYPERGLYCEMIA 
56 
10.3 IDENTIFICATION OF ADVERSE EVENTS BY THE INVESTIGATOR ................................................. 56 
10.4 REPORTING OF ADVERSE EVENTS ................................................................................................. 57 
10.5 REPORTING OF SERIOUS ADVERSE EVENTS ................................................................................. 57 
10.5.1 REPORTING BY THE INVESTIGATOR 
57 
10.5.2 REPORTING SAES TO THE HEALTH AUTHORITIES AND ETHICS COMMITTEES 
58 
10.6 ADDITIONAL SAFETY ASSESSMENTS ............................................................................................. 58 
10.6.1 VITAL SIGNS 
58 
10.6.2 BIOCHEMISTRY AND HEMATOLOGY 
59 


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10.7 12-LEAD ELECTROCARDIOGRAM MONITORING. ......................................................................... 59
10.8 CONCOMITANT MEDICATIONS ...................................................................................................... 59 
10.9 SAFETY AND DATA REVIEW ........................................................................................................... 59 
10.10 FOLLOW-UP AND REPORTING OF PREGNANCIES ....................................................................... 59 
11 STATISTICS ....................................................................................................................... 61 
11.1 SAMPLE SIZE CONSIDERATIONS .................................................................................................... 61 
11.2 ANALYSIS POPULATIONS ................................................................................................................ 61 
11.2.1 ITT POPULATION 
61 
11.2.2 PER PROTOCOL POPULATION 
61 
11.3 ANALYSIS OF PRIMARY EFFICACY OUTCOME ............................................................................. 61 
11.4 KEY SECONDARY OUTCOME ANALYSIS ........................................................................................ 62 
11.5 ANALYSIS OF SECONDARY EFFICACY OUTCOMES ....................................................................... 63 
11.5.1 MODIFIED RANKIN SCALE – SHIFT ANALYSIS 
64 
11.5.2 NATIONAL INSTITUTES OF HEALTH STROKE SCALE 
64 
11.5.3 BARTHEL INDEX 
64 
11.5.4 MORTALITY RATE 
64 
11.5.5 MODIFIED RANKIN SCALE – 0-1 DICHOTOMY ANALYSIS 
64 
11.6 ANALYSIS OF TERTIARY EFFICACY OUTCOMES .......................................................................... 64 
11.6.1 EQ-5D-5L 
64 
11.6.2 VOLUME OF STROKE 
64 
11.6.3 COGNITIVE OUTCOMES 
64 
11.6.4 MRS AT 30 DAYS 
65 
11.6.5 PHARMACOKINETICS 
65 
11.7 ADJUSTMENT FOR COVARIATES AND SUBGROUP ANALYSES ...................................................... 65 
11.8 HANDLING OF MISSING, UNUSED AND SPURIOUS DATA .............................................................. 65 
11.9 ANALYSES OF SAFETY .................................................................................................................... 65 
11.9.1 SAES 
65 
11.9.2 MORTALITY 
66 
11.9.3 AES 
66 
11.9.4 VITAL SIGNS 
66 
11.9.5 LABORATORY AND 12-LEAD ECG RESULTS 
66 
11.9.6 PRIOR AND CONCOMITANT MEDICATIONS 
66 
11.10 INDEPENDENT DATA MONITORING COMMITTEE....................................................................... 66 
12 DIRECT ACCESS TO SOURCE DATA/DOCUMENTS ............................................... 68 
13 QUALITY CONTROL AND QUALITY ASSURANCE ................................................ 69 
13.1 AUDITS AND INSPECTIONS .............................................................................................................. 70 
13.2 PROTOCOL AMENDMENTS AND REVISIONS .................................................................................. 70 
14 ETHICS ................................................................................................................................ 71 
14.1 RESEARCH ETHICS BOARD/INSTITUTIONAL REVIEW BOARD .................................................... 71 
15 DATA HANDLING AND RECORDKEEPING .............................................................. 72 
15.1 DATA HANDLING ............................................................................................................................ 72 
15.2 INVESTIGATOR FILES/RETENTION OF DOCUMENTS .................................................................... 72 
15.3 SOURCE DOCUMENTS AND BACKGROUND DATA ......................................................................... 72 
15.4 CASE REPORT FORMS .................................................................................................................... 73 


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15.5 CONFIDENTIALITY .......................................................................................................................... 73 
16 PUBLICATION AND PRESENTATION POLICY ........................................................ 74 
17 ANCILLARY STUDIES POLICY .................................................................................... 74 
18 DATA-SHARING PLAN .................................................................................................... 75 
19 FINANCIAL CONSIDERATIONS ................................................................................... 76 
20 APPENDIX 1 – ADDITIONAL GUIDANCE ON IMAGING SELECTION AND 
ENDOVASCULAR TREATMENT .......................................................................................... 77 
21 APPENDIX 2: DERIVATION OF ASPECTS ON NCCT AND COLLATERALS 
SCORING ON CTA ................................................................................................................... 81 
22 APPENDIX 3 – RANDOMIZATION DETAILS. ............................................................ 84 
23 REFERENCES .................................................................................................................... 85 
24 INVESTIGATOR’S AGREEMENT ................................................................................. 88 


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Tables and Figures 
Figure 1: Inhibition of NO production by NA-1 via perturbation of NMDAR-PSD-95 
interactions [Ca=calcium; nNOS=neuronal nitric oxide synthase] .............................................. 21 
Table 2-1: Schedule of Assessments............................................................................................. 17 
Table 10-1: Definitions of AE-Related Terms.............................................................................. 54 


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1.2 
List of Abbreviations 
3PVO 
Permanent Occlusion 3 Pial Vessels 
ABC 
Airway, Breathing, Circulation 
ADC 
Apparent Diffusion Coefficient 
AIS 
Acute Ischemic Stroke 
ANCOVA 
Analysis of Covariance 
ANOVA 
Analysis of Variance 
aPTT 
Activated Prothrombin Time 
AE 
Adverse Event 
ASA 
Acetylsalicylic Acid 
ASPECTS 
Alberta Stroke Program Early Computerized Tomography Score 
β-hCG 
Beta-human Chorionic Gonadotropin 
BI 
Barthel Index 
BNT 
Boston Naming Test 
BP 
Blood Pressure 
Ca 
Calcium 
CBC 
Complete Blood Count 
CBV 
Cerebral Blood Volume 
CFR 
Code of Federal Regulations 
CI 
Confidence Interval 
CRF 
Case Report Form 
CRU 
Clinical Research Unit 
CT 
Computed Tomography 
CTA 
Computerized Tomographic Angiography (multiphase or dynamic) 
CTP 
Computerized Tomographic Perfusion 
DWI 
Diffusion Weighted Imaging’ 
DVT 
Deep Vein Thrombosis 
ECG 
Electrocardiogram 
e-CRF
Electronic Case Report Form 
ED
Emergency Department  
EDC
Electronic Data Capture 
EMA
European Medicines Agency 
EVT
Endovascular Treatment 
FDA
Food and Drug Administration 
FLAIR
Fluid Attenuated Inversion Recovery 
HIA
Health Information Act 
HIPAA
Health Insurance Portability and Accountability Act 
HIV
Human Immunodeficiency Virus 
IA
Intra-arterial 
ICA
Internal Carotid Artery 
ICH
Intracranial Hemorrhage 
ICH-GCP
International Conference on Harmonization-Good Clinical Practice 
IDMC
Independent Data Monitoring Committee 
INR
International Normalized Ratio 
IOML
Inferior Orbitomeatal Line 


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IRB 
Institutional Review Board 
ITT 
Intent-to-treat 
IVH 
Intraventricular Hemorrhage 
IV 
Intravenous 
LAR 
Legally Authorized Representative 
MAP 
Mean Arterial Pressure 
MCA 
Middle Cerebral Artery 
MCAO 
Middle Cerebral Artery Occlusion 
MedDRA 
Medical Dictionary for Regulatory Activities 
MI 
Myocardial Infarction 
MIPS 
Maximum Intensity Projections 
MoCA 
Montreal Cognitive Assessment 
MR 
Magnetic Resonance 
MRI 
Magnetic Resonance Imaging 
mRS 
Modified Rankin Scale 
MRP 
Magnetic Resonance Perfusion 
Na+ 
Sodium 
NaCl 
Sodium Chloride 
NCCT 
Non-contrast Computed Tomography Scan 
NHPSS 
Non-human Primate Stroke Scale 
NIHSS  
National Institutes of Health Stroke Scale 
NINDS 
National Institute of Neurological Disorders and Stroke 
NMDA 
N-methyl D-aspartate
NMDAR 
N-methyl D-aspartate Receptor
nNOS 
Neuronal Nitric Oxide Synthase
NO 
Nitric Oxide
O-F
O’Brien-Fleming
OLS
Ordinary Least Squares
OR
Odds Ratio
PEG
Percutaneous Endoscopic Gastrostomy
pH
Potential Hydrogen
PI
Principal Investigator
PIPEDA
Personal Information and Portable Electronic Documents Act
PK
Pharmacokinetic
pMCAO
Permanent Middle Cerebral Artery Occlusion
PP
Per Protocol
PSD-95
Post-synaptic Density 95 Protein
REB
Research Ethics Board
RNA
Ribonucleic Acid
RR
Risk Ratio
SAE
Serious Adverse Event
SAH
Subarachnoid Hemorrhage
SaO2
Oxygen Saturation
SAP
Statistical Analysis Plan
SBP
Systolic Blood Pressure


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SDH  
Subdural Hematoma 
SNAP  
Sunnybrook Hemispatial Neglect Procedure 
SOC  
System Organ Class 
SOP 
 
Standard Operating Procedures 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TIA 
 
Transient Ischemic Attack 
TICI 
 
Thrombolysis in Cerebral Infarction Score 
TIMI  
Thrombolysis in Myocardial Infarction 
tMCAO 
Transient Middle Cerebral Artery Occlusion 
tPA 
 
Tissue Plasminogen Activator (generic name = alteplase) 
USA/US 
The United States of America 
WFNS  
World Federation of Neurological Surgeons 
WHO  
World Health Organization 
 
 
 


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2 
Study Synopsis 
Trial Objectives 
The primary objective is to determine the efficacy of the 
neuroprotectant, NA-1, in reducing global disability in subjects with 
major acute ischemic stroke (AIS) with a small established infarct core 
and with good collateral circulation selected for rapid endovascular 
revascularization. 
The secondary objectives are to determine the efficacy of NA-1 in: 
•
Reducing functional dependence
•
Improving neurological outcome
•
Improving activities of daily living
•
Reducing mortality rate
The leading 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 (IV) infusion of NA-1 to subject with acute stroke who are 
selected for endovascular revascularization on serious adverse events 
(SAEs) and 90-day mortality. 
Trial Design 
This study is a Phase 3, randomized, multicentre, blinded, placebo-
controlled, parallel group, single-dose design. Subjects harboring an 
acute ischemic stroke and who are selected for endovascular 
revascularization in accordance with local institutional practices and 
who harbor a small established infarct core and with good collateral 
circulation will be given a single, 2.6 mg/kg (up to a maximum dose of 
270 mg) intravenous dose of NA-1 or placebo as soon as they are 
deemed to have met the enrollment criteria and with the intention of 
starting administration within 30 minutes of randomization. The 
randomization will be by stochastic minimization to balance baseline 
factors. 
Subjects 
Up to 1120 male and female subject will be enrolled. 
Inclusion Criteria 
1) Acute ischemic stroke (AIS) for immediate endovascular treatment
2) Age 18 or greater.
3) Onset (last-seen-well) time to randomization time within 12 hours.
4) Disabling stroke defined as a baseline National Institutes of Health
Stroke Score (NIHSS) > 5 at the time of randomization.
5) Pre-stroke (24 hours prior to stroke onset) independent functional
status in activities of daily living with modified Barthel Index (BI)
> 90 (95 or 100).  Patient must be living in their own home,
apartment or seniors lodge where no nursing care is required.
6) Confirmed symptomatic intracranial occlusion, based on multiphase
or dynamic computerized tomographic angiography (CTA), at one
or more of the following locations: Intracranial carotid T/L, M1
middle cerebral artery (MCA). Functionally, when defining the M1
or the M2, the bulk of the MCA territory must be ischemic.


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7) Non-contrast computed tomography (NCCT) and CTA* for trial
eligibility performed or repeated at ESCAPE-NA1 stroke centre
with endovascular suite on-site.
8) Endovascular treatment with declared first endovascular approach
as either stent retriever or aspiration device, and intended to be
initiated (arterial access) within 60 minutes of baseline/qualifying
NCCT and to first recanalization of 90 minutes.  Study drug
intended to be administered within 60 minutes of the
baseline/qualifying NCCT.
9) Signed informed consent from subject or legally authorized
representative or, if required to enable inclusion by applicable
national laws and regulations and the applicable independent review
boards/Ethics Committee requirements for obtaining consent, from
the investigator after consultation with an independent physician
who is not otherwise participating in the trial.
*As per the List of Abbreviations (Section 1.2), all references to CTA
indicate a multiphase or dynamic CTA.
Exclusion Criteria 
1) Evidence of a large core of established infarction defined as
ASPECTS 0-4.
2) Evidence of absence of collateral circulation on CTA (Collateral
score of 0 or 1).
3) Intent to use any endovascular device other than a stent retriever
or clot aspiration device or intra-arterial medications as the
initial thrombectomy approach.
4) Intent to use any intravenous thrombolytic other than alteplase
if intravenous thrombolysis is planned.
5) No femoral pulses, very difficult endovascular access or extreme
tortuosity of great vessels that is predicted to result in an
inability to deliver timely endovascular therapy.  Direct
common carotid or radial/brachial/axillary access is permissible.
6) Estimated or known weight > 120 kg or < 45 kg.
7) Pregnancy; if a woman is of childbearing potential a urine or
serum beta human chorionic gonadotropin (β-hCG) test is
positive, or breastfeeding.
8) Severe contrast allergy or absolute contraindication to iodinated
contrast preventing endovascular intervention, including any
contraindications listed in the prescribing information approved
by local authorities (e.g., patients with decompensated heart
failure as a contraindication for the use of VISIPAQUETM 270
in Germany).
9) Clinical history, past imaging or clinical judgment suggests that
the intracranial occlusion is chronic or there is suspected


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intracranial dissection such that there is a predicted lack of 
success with endovascular intervention. 
10) Prior enrolment in the ESCAPE-NA1 trial or prior receipt of
NA-1 for any reason.
11) Severe known renal impairment defined as requiring dialysis
(hemo- or peritoneal) or if known a creatinine clearance < 29
mL/min.
12) Patient has a severe or fatal comorbid illness that will prevent
improvement or follow-up.
13) Patient cannot complete follow-up treatment due to co-morbid
non-fatal illness or they are known to be a visitor to the city or
any other known reason for which follow-up would be
impossible (e.g. incarcerated in a federal prison).
14) Participation in another clinical trial investigating a drug,
medical device, or a medical procedure in the 30 days
preceding study inclusion.
Countries 
Canada, Ireland, Sweden, U.S., South Korea, United Kingdom, 
Australia, Germany 
Treatment 
NA-1 2.6 mg/kg (up to a maximum dose of 270 mg, or matching normal 
saline placebo volume) will be administered as a single 10 ± 1 minute 
intravenous infusion in the upper or lower extremity using an infusion 
pump starting after randomization.  All subjects will undergo attempted 
endovascular recanalization therapy with the intended endovascular 
approach being either using a stent retriever or clot aspiration device 
and receive best medical care according to modern acute stroke care 
guidelines. 
Stent retrievers or aspiration devices will be used according to current 
local jurisdictional guidelines.  
Consent 
Signed informed consent will be obtained prior to any protocol-specific 
procedures from the subject or legally authorized representative or, if 
required to enable inclusion by applicable national laws and regulations 
and the applicable independent review boards/Ethics Committee 
requirements for obtaining consent, from the investigator, after 
consultation with an independent physician who is not otherwise 
participating in the trial.  
If the original process involved anyone other than the subject and if 
required by local standards, consent will be sought for the remaining 
procedures from the subject once they are deemed to have regained 
capacity. 
Randomization 
Method 
Treatment will be assigned using 1:1 randomization (placebo:NA-1) 
with a stratification and minimization algorithm to minimize the 


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contribution of imbalances in baseline factors and non-randomized 
therapies (e.g., alteplase use) to differences between treatment groups. 
Duration of 
Treatment 
This study consists of one 90-day study period for each subject.  
Subjects will be hospitalized for care after their acute stroke according 
to the current standard of care.  Subjects are required to return to clinic 
on Days 30 and 90 for end-of-study procedures.   
Laboratory 
Tests 
In order to support the assessment of patient safety baseline (pre-dose) 
and post dose hematology and chemistry laboratory tests will be 
collected.  
At baseline, and at 24 ± 12 hours after study drug infusion and 
termination of EVT blood work will be evaluated which include: 
complete blood count (CBC), electrolytes, international normalized 
ratio (INR), activated prothrombin time (aPTT), serum creatinine and 
serum glucose. 
Other laboratory or point-of-care testing may be performed at the 
discretion of the attending physicians and team.  
If the subject 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. 
Electrocardiograms will also be collected and reviewed at baseline (pre-
dose, unless impeding access to timely intervention) and at 24 hours. 
Assessment of 
Efficacy and 
Power 
The primary efficacy outcome variable for the pivotal assessment of 
efficacy for regulatory submission purposes is the overall proportion of 
subjects experiencing a favorable functional outcome 90 days post-
randomization, defined as a score of 0 to 2 on the modified Rankin Scale 
(mRS). These subjects are defined to be responders.  Assuming a 52% 
overall responder rate for the placebo group, there will be an 
approximately 80% power to detect an 8.7% absolute effect difference 
between response rate (proportion of responders, with Day 90 mRS in 
the range 0 to 2) with NA-1 and placebo, at alpha level 0.05, 2-sided 
with a planned sample size of 1076 evaluable subjects, randomized 1:1, 
per group, accounting for a single interim analysis when 600 subjects 
have completed their 90 day follow up visit information (600 subjects 
with primary endpoint assessments) with O’Brien-Fleming alpha-
spending function stopping boundary for overwhelming efficacy and a 
non-binding 1% conditional power futility stopping boundary (EaST® 
V6.3). The sample size will be inflated approximately 4% to N=560 per 
group to account for loss-to-follow-up and drop-outs.  
The primary hypothesis to be tested is that administration of NA-1 will 
result in an increase in the proportion of subjects with independent 
functioning on the mRS (as defined by a score of 0-2) at Day 90.  The 


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primary analysis will be a Wald test for treatment group difference in 
the primary outcome from a logistic regression including treatment and 
the following important prognostic factors: intravenous alteplase 
treatment, intended initial endovascular approach as well as age, sex 
baseline NIHSS score, baseline ASPECTS score, occlusion location and 
site.  
The primary efficacy analysis and secondary endpoint analyses will be 
conducted on the intent-to-treat (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.  
A key secondary outcome analysis is planned to evaluate a shift of one 
or more categories to reduced functional dependence analyzed across 
the whole distribution of scores on the mRS at Day 90 or the last rating. 
This secondary outcome will be an adjusted analysis using a 
proportional odds model to derive the common odds of improvement 
(“shift”) along the mRS scale.  Adjustment will include all of the 
variables used in stratification (intravenous alteplase treatment, 
intended initial endovascular approach) and in the minimization 
algorithm (age, sex, baseline NIHSS score, baseline ASPECTS score, 
occlusion location, and site). The proportional odds assumption will be 
tested. 
Other secondary outcomes include: 
1) Proportion of subjects with good neurological outcome, as
defined by a score of 0-2 on the NIHSS at Day 90 or the last
rating.
2) Proportion of subjects with functional independence in activities
of daily living, as defined by a score of ≥ 95 on the BI at Day 90
or the last rating.
3) A reduction in mortality rate, as defined by event rate (%) for
mortality over the 90 day study period
4) Proportion of subjects with functional independence, as defined
by a score of 0-1 on the mRS at Day 90 or the last rating.
Assessment of 
Safety 
For the safety analysis, the frequency of SAEs, 90-day mortality, 
adverse events (AEs), discontinuations due to AEs.  As well, baseline 
and post-dose study drug vital signs, laboratory (hematology and 
chemistry) and electrocardiogram (ECG) findings will be analyzed.   
Independent 
Data Monitoring 
Committee 
An Independent Data Monitoring Committee (IDMC) will perform 
periodic safety reviews of the clinical data. The reviews will occur once 
100, 300 and 600 subjects have reached their Day 90 final study visit. 
An efficacy interim analysis (after approximately 600 subjects complete 


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the Day 90 follow-up) will be conducted using the alpha spending 
function method1 with O’Brien and Fleming2 type stopping boundary 
for efficacy and a non-binding conditional power boundary for futility. 
The trial may be stopped for overwhelming efficacy or futility at the 
interim analysis if the test statistic crosses the O’Brien-Fleming (O-F) 
or conditional power boundary. 
Bioanalytical 
Methods 
The plasma concentrations (immunogenicity) of NA-1 from a subset of 
up to 250 subjects from sites located in Canada and the USA will be 
analyzed using a validated direct ELISA assay method. 
Pharmacokinetic assessments from a subject of up to 100 subjects from 
a subset of sites located in Canada and the USA will be evaluated. 


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Table 2-1: Schedule of Assessments 
Baseline 
Post-
EVT 
(~2 h) 
Day 1 
(24 ± 12 h 
from random-
ization) 
Day 2 
(48 ± 8 h from 
randomization) 
Day 5 or 
discharge 
(±1 d) 
Day 30 
(±5 d) 
Day 
90 
(±14 
d) 
Informed consent 
X 
Attempt at regained capacity 
informed consent★ 
X 
X 
X 
X 
X 
History and examination 
X 
Weight 
X* 
X (Actual) 
Vital Signs (BP, HR, Temp) ★★
X 
X 
X 
X 
X 
Randomization/ Study drug 
administration 
X 
Mortality 
X 
X 
X 
NIHSS 
X 
X 
X 
X 
X 
X 
X 
mRS 
X¶ 
X 
X 
X 
Barthel Index 
X 
X 
X 
BNT15, SNAP, MoCA¶¶ 
X 
EQ-5D-5L 
X 
X 
NCCT head 
X 
CTA (Circle of Willis) 
X 
Endovascular Procedure 
X 
MR head 
X** 
CBC  (hemoglobin, platelets 
and hematocrit), electrolytes 
(sodium, potassium, chloride), 
INR, aPTT, serum creatinine 
and serum glucose 
X‡ 
X 
Pregnancy test 
X‡‡ 
Immunogenicity sample‡‡‡ 
X 
X 
Pharmacokinetic samples‡‡‡‡ 
X 
ECG 
X§ 
X 
AE assessment 
Collected to Day 30 visit 
SAE assessment 
Collected to Day 90 visit 
Prior medications 
X§§
Concomitant medications 
Collected to Day 30 visit 
★If the original process involved anyone other than the subject (and if required), site staff will make ongoing efforts until (1) regained
capacity consent is obtained from subject, (2) death, or (3) completion of the Day 90 assessment.
★★Vitals signs (BP, HR only) should be recorded immediately before and after completion of the study drug infusion, temperature will
be taken at baseline per standard of care.
¶ Historical (pre-stroke) mRS score can be collected at any time and will be reported on the 24h CRF.
¶¶ Assessments will be conducted only if the tool/scale is available in local language.
* At baseline estimated or actual weight
**Day 1 MR head may be supplanted by an NCCT head if MR is unavailable or contraindicated.
‡ Blood should be drawn at baseline, but results are not required prior to randomization.
§For ECG, if treating physician deems that pre-treatment ECG impedes access to timely care, ECG must be completed within 6 hours 
of randomization.
‡‡ If the subject 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.
‡‡‡ Immunogenicity samples will be taken from a subset of up to 250 subjects at Canadian and US sites only.
‡‡‡‡ PK samples will be taken from up to 100 subjects at a subset of Canadian and US sites.  Samples will be taken at pre-dose and at
10, 20, 30, 60 and 120 min after the start of drug administration.
§§Prior medications should be documented but their documentation not required prior to randomization.
d = days; h = hours


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3 
Coordinating Centre, Sponsor, Investigators and Facilities 
Coordinating Centre 
University of Calgary 
Foothills Medical Center 
1403 29th Street NW 
Calgary, AB T2N 2T9 
Sponsor: 
NoNO Inc 
Krembil Research Institute 
8KD-406 60 Leonard Avenue 
Toronto, ON Canada M5T 2S8 
Sponsor Medical Oversight: 
Michael Tymianski, M.D., Ph.D., F.R.C.S.C. 
Project Director: 
Senior Project Leader 
Overall Coordinating 
Investigator: 
Co-Coordinating 
Investigators 
President and CEO, NoNO Inc. 
NoNO Inc 
NoNO Inc 
Michael D. Hill M.D., MSc, F.R.C.P.C. 
Director, Calgary Stroke Unit  
University of Calgary 
Mayank Goyal, M.D., F.R.C.P.C. 
Director of Research, Department of Diagnostic Imaging 
Bijoy K. Menon, MD, DM, MSc 
Assistant Professor Departments of Clinical Neurosciences, 
Radiology and Community Health Sciences 
redacted
redacted


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Data Management Center: 
Imaging Management 
Centre: 
Clinical Research Unit (CRU) 
University of Calgary 
Calgary Image Processing and Analysis Center (CIPAC), 
University of Calgary 


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4 
BACKGROUND INFORMATION 
4.1 
Rationale  
The rationale for this study is the following: 
1) There is no convincing evidence from randomized controlled trials that neuroprotection can be
of clinical benefit to patients with AIS.   There is however, extensive preclinical evidence that
neuroprotection is of greatest benefit for improving functional outcome in studies employing
experimental animal stroke models in which stroke is followed by reperfusion, as compared
with stroke models in which arterial vessel occlusion is undertaken without reperfusion.
2) The ESCAPE and other recent trials of endovascular thrombectomy for AIS have demonstrated
that modern acute endovascular therapy can rapidly recanalize blocked major arteries in
patients with acute stroke arising from large artery occlusion with a low complication rate and
high complete reperfusion rates.3-7  This paradigm replicates the preclinical animal ischemia-
reperfusion models in which neuroprotectants have the highest demonstrated efficacy.
3) The neuroprotectant, NA-1, has been demonstrated to be highly effective in reducing stroke
size and improving the functional outcome of experimental animals subjected to acute stroke,
including rats and primates. NA-1 is more effective in reducing infarct size and improving
functional outcome in models of ischemia-reperfusion, as compared with permanent arterial
occlusion8,9,10.
4) NA-1 has an excellent safety profile in preclinical animal studies, a human Phase 1 trial, and a
human Phase 2 study (the ENACT trial).11 Patients in the ENACT trial were also individuals
who were being subjected to an endovascular procedure (intracranial aneurysm repair) and to
treatment with NA-1 or placebo.
5) NA-1 is the only neuroprotectant to have been shown to reduce ischemic brain damage in
humans having demographics similar to those of stroke patients.
6) The inclusion/exclusion criteria of the ESCAPE trial3 were successful in identifying patients
with salvageable brain (an ischemic penumbra). Modern endovascular techniques have
extremely high rates of safe and effective reperfusion. This makes the ESCAPE patient
selection process and use of endovascular recanalization an ideal clinical paradigm to replicate
prior preclinical animal studies that support the effectiveness of the neuroprotectant, NA-1.
7) There is a compelling need to develop neuroprotectants in order to increase the proportion of
patients who may benefit from recanalization therapies. These agents could improve the
outcomes of those who receive endovascular recanalization, and make more patients into
candidates for endovascular or pharmacological recanalization treatments.
4.2 
The Neuroprotectant, NA-1 
NA-1 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)12, 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 NA-1.  The ability to identify patients with salvageable 
brain using the criteria used in the ESCAPE trial provides an opportunity to target patients who 


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may have the greatest benefit from neuroprotection, and to enhance further the impact of 
reperfusion therapies3. Our preclinical and clinical data support this notion. 
NA-1 is composed of two parts: a 9-amino acid active substance that binds to PSD-95, and an 11-
amino acid sequence derived from the human immunodeficiency virus (HIV)-1 Tat protein which 
permits NA-1 to penetrate through the blood-brain barrier and enter neuronal target cells.  PSD-
95 couples transmembrane proteins such as the N-methyl-D-aspartate (NMDA) subtype of 
glutamate receptors to various intracellular signaling enzymes that mediate the neurotoxic sequelae 
of NMDA receptor activity. Specifically, NA-1 inhibits the interaction between PSD-95 and the 
GluN2B subunit of the NMDA receptor (NMDAR), thus uncoupling NMDARs from downstream 
neurotoxic signaling enzymes and preventing or limiting the onset of excitotoxicity that is 
associated with AIS (Figure 1). NA-1 has no known effect on the electrophysiological aspects of 
NMDAR channel function, but results in decreases in pro-death signals downstream of NMDARs 
such as reduced production of the toxic free radical nitric oxide (NO). 13 
Figure 1: Inhibition of NO production by NA-1 via perturbation of NMDAR-PSD-95 interactions 
[Ca=calcium; nNOS=neuronal nitric oxide synthase] 
4.3 
Summary from Nonclinical Studies and Clinical Trials 
NA-1 has been shown to be a promising neuroprotectant in rats and in non-human primates 
exposed to experimental strokes when it is administered within three hours of stroke onset8,13. It is 
also effective in reducing iatrogenic stroke burden in humans subjected to endovascular aneurysm 
repair as measured by a reduction in the number of new lesions visualized by magnetic resonance 
imaging (MRI)11. In the human study, NA-1 was administered on average within two hours after 
initiation of the aneurysm repair procedure. These preclinical and clinical findings are consistent 
with the well-established notion that there must still be brain left to salvage in order for any 
neuroprotectant to result in a benefit to patients with AIS14. All these studies had in common the 
fact that NA-1 was administered in a paradigm in which stroke damage was not yet complete. See 
Figure 1: Inhibition of NO production by NA-1 via perturbation of NMDAR-PSD-95 
interactions [Ca=calcium; nNOS=neuronal nitric oxide synthase] 


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4.3.1 Nonclinical Studies 
4.3.1.1 NA-1 Effect on Infarct Size and Volume in Rodent Models of Stroke 
Several in vivo pharmacology studies have been conducted with NA-1 in rodents to evaluate the 
effect of NA-1 on infarct size and volume in models of stroke involving either transient or 
permanent occlusion of intracranial arteries, and effects on sensory, emotional, and cognitive 
deficits.  The results of the rodent studies demonstrated that NA-1 is delivered to the brain of an 
intact animal following systemic exposure via intravenous administration, and also appears to 
accumulate at sites of brain injury when given intravenously after animals had been subjected to a 
cortical stroke induced by permanent occlusion 3 pial vessels (3PVO model)9. When administered 
intravenously, post-insult treatment with NA-1 (0.08 to 7.60 mg/kg) in a transient stroke model 
produced by middle cerebral artery occlusion (tMCAO) is effective in both permanently reducing 
stroke size, and in improving neurological function even when treatment is administered as late as 
three hours after stroke onset. There was no effect on normal central nervous system function. Rats 
treated with NA-1 had reduced motor, sensory, emotional, and cognitive deficits, as well as faster 
recovery of pre-surgery weight. NA-1 has been shown to be efficacious in models of permanent 
stroke in rats at a dose of 7.6 mg/kg when administered one-hour post-insult9. Furthermore, Fisher 
and colleagues found that administration of NA-1 in a rat model of permanent middle cerebral 
artery occlusion (pMCAO) “froze” the ischemic penumbra measured using MRI15. In other words, 
NA-1 administration in the face of an evolving ischemic injury halted the progression of further 
brain damage as of the time it was administered.  
4.3.1.2 Effect of NA-1 in Reperfused MCAO Model of AIS in Non-Human Primates (30-Day 
Study) 
To test whether NA-1 is neuroprotective in acute AIS in a gyrencephalic species, a blinded, 
randomized trial of NA-1 versus drug vehicle in a tMCAO model in 20 cynomolgus macaques was 
completed8. NA-1 2.6 mg/kg or drug vehicle were administered in blinded fashion 60 minutes 
following middle cerebral artery occlusion (MCAO). The MCA was reperfused 90 minutes 
following occlusion. Stroke volume on 24 hour MRI diffusion weighted imaging (DWI) was 
statistically significantly reduced by over 50% in NA-1-treated animals as compared with placebo 
animals and this effect was maintained on the Day 30 MRI. There was also a significant 
improvement in Non-Human Primate Stroke Score (NHPSS) and significant improvements in 
sensory and motor function. 
There were no differences in any of the physiological parameters [including mean arterial pressure 
(MAP)] for NA-1 and placebo treated animals, with the exception of temperature at the time of 
MRI completion (36.5oC ± 0.27 in placebo treated animals versus 37.4oC ± 0.16 in NA-1 treated 
animals, p=0.015).   
4.3.1.3 Effects of NA-1 on Infarct Volume and Gene Transcription Response in pMCAO 
Model of AIS in Cynomolgus Macaques 
To test the neuroprotective effect of NA-1 on infarct volume and gene transcription response, six 
macaques underwent pMCAO, with NA-1 or placebo treatment administered five minutes after 
ischemia onset.   DWI MRI scans were taken every 15 minutes. The volume of brain in which 


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DWI hyperintensity was detectable increased over time in both groups.  However, treatment with 
NA-1 attenuated the rate of this increase by about twofold (p=0.019).  Moreover, within the 
ischemic volume, DWI intensity in brains of NA-1-treated animals remained lower than that of 
untreated controls, suggesting that tissue within the infarct volume maintained better integrity8. 
Tissue was collected from the ischemic penumbras (adjacent to infarcted tissue) and from 
corresponding sites in the contralateral non-ischemic hemisphere at one and six hours after 
ischemia onset. Ribonucleic acid (RNA) was extracted and hybridized to whole-genome macaque 
arrays. Differential gene expression analysis revealed that treatment with NA-1 resulted in a lower 
proportion of down regulated genes and preservation of the capacity to up regulate genes at both 
one and six hours after stroke.  Overall, the genome-wide survey suggested that neuroprotection 
with NA-1 preserved cellular functionality as gauged by the capacity for gene transcription in 
ischemic brain tissue8. 
4.3.1.4 Effect of NA-1 in Prolonged tMCAO Model of AIS (7-Day Study) 
The hypothesis that NA-1, administered one hour into a 4.5 hour tMCAO in cynomolgus macaques 
(which is the limit of effectiveness of alteplase in a human reperfusion study16) would improve 
stroke neurological outcomes and reduce stroke volumes seven days following stroke was tested. 
Six animals received NA-1 (2.6 mg/kg IV) and six received placebo one hour following MCAO. 
The MCA was reperfused 4.5 hours after MCAO.  There was a significant reduction in stroke 
volume (relative reduction of 25%) in the NA-1 group in comparison with the placebo group. 
Scores on the NHPSS were significantly improved in NA-1 treated animals at seven days8. There 
were no differences in any of the physiological parameters (including MAP) at any of the measured 
time points for the NA-1 versus placebo treated animals.   
4.3.1.5 Effect of NA-1 Administered Three Hours After Onset of 3.5 Hour tMCAO in 
Cynomolgus Macaques (14-Day Study) 
To test whether NA-1 is beneficial when administered later in the setting of a prolonged tMCAO, 
24 cynomolgus macaques received a 10-minute infusion of NA-1 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.  NA-1 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 NA-1 exhibited improved NHPSS scores throughout the 14-day observation period 
days [p=0.004, two-way repeated measures analysis of variance (ANOVA)] and trended to better 
performance in the six-well and the valley staircase tasks8. There were no statistically significant 
differences in any of the physiological parameters (including MAP) at any of the measured time 
points for the NA-1 versus placebo treated animals.    
We have reviewed the outcomes using analyses analogous to those proposed in the current 
protocol, but using the available NHPSS scores instead of the mRS scores proposed in this current 
trial. 


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Analogous to our proposed analysis of the primary outcome using a dichotomy approach, the 
NHPSS was divided in a binary fashion defining good outcome as NHPSS 0-2 at 14 days.  With 
this, we calculated the risk ratio (RR) = 3.0 (0.7-12.0), p = 0.193, with an absolute risk difference 
of:  0.33 (CI95 -0.02 – 0.69). Alternatively, using simple ordinary least squares (OLS) linear 
regression, NHPSS = -3.5*trt + 6.9, p(β-coeff) = 0.005.  So on average at 14 days, the NHPSS was 
3.5 points less in the treated group. 
By analogy to one of our proposed 
secondary analyses using a proportional 
odds model (‘shift 
analysis’), we 
presented the outcome on the NHPSS 
divided in quartiles at 14 days.  Note that 
the NHPSS shift here is calculated by 
quartiles of NHPSS and not by pre-
specified groups. 
Common odds ratio (OR; (proportional 
odds model) for shift along the NHPSS = 
8.1 [Confidence Interval (CI)95 1.5-
45.3)], p = 0.016. 
4.3.1.6 Efficacy of NA-1 in Reducing the Number and Volumes of MRI-visible Strokes in a 
Cynomolgus Macaque Model of Micro-embolic Stroke 
A study of the efficacy of NA-1 in reducing the number and volume of MRI-visible strokes in a 
cynomolgus macaque model of microembolic stroke was completed10. The purpose of the study 
was to evaluate NA-1 in an experimental setting that mimics the MRI-detectable strokes sustained 
by human patients as a result of endovascular brain aneurysm repair. The study evaluated the 
effects of an intravenous dose of NA-1 2.6 mg/kg on the volume and number of cerebral infarcts 
produced by an intra-arterial injection of 20 100μm polystyrene spheres in cynomolgus macaque 
monkeys, an experimental embolic stroke paradigm that produces a permanent occlusion of the 
affected brain vessels. 
Ten cynomolgus macaques were randomized to receive NA-1 2.6 mg/kg or placebo. Following 
induction of anesthesia, each animal underwent insertion of a femoral angiography catheter and a 
cerebral angiogram was performed. Each animal then received an injection of 20 100μm 
polystyrene sphere emboli. At one hour following the embolic procedure, NA-1 (2.6 mg/kg) or 
placebo [equivalent volume of 0.9% sodium chloride (NaCl)] was infused intravenously in 5 mL 
of 0.9% NaCl over 10 minutes. Animals underwent diffusion and T2-weighted imaging at four 
hours after the injection of emboli. Twenty-four hours after the embolic procedure, the animals 
were re-anesthetized and returned to the MRI scanner for further DWI and T2 imaging. A further 
MRI at four weeks was utilized to confirm that DWI hyperintensities had resolved completely. 
After this 4-week washout period, each animal was crossed over to the opposite treatment group 
and the experiment was repeated.  


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All 10 animals completed the first iteration of the crossover trial. On the second round, three 
animals were lost due to an air embolus in a placebo animal, a post-operative aspiration in a 
placebo animal, and an anesthetic related cardiac arrest preceding surgery and dosing in the third. 
There were no significant differences in physiologic parameters between groups (including MAP). 
Animals treated with NA-1 exhibited markedly reduced stroke numbers and volumes as compared 
with placebo-treated animals. Numbers of total strokes were: 4.7 ± 0.16 and 12.75 ± 0.15 in NA-
1 versus placebo respectively (p<0.001). Volumes of total strokes were: 28.4 ± 2.98 and 64.4 ± 
3.41 in NA-1 versus placebo respectively (p = 0.015).  
This study revealed that counting the number and/or volume of new, small lesions incurred by 
small intra-arterial emboli is a useful bio-assay that can detect the consequences of penetration of 
a study drug into target brain tissue and to measure its intended biological effect on reducing stroke 
damage.  
4.3.1.7 Nonclinical Primary Pharmacology Summary 
In summary, NA-1 is a novel peptide that has now been repeatedly shown to protect 
against ischemic damage following stroke in several rodent and non-human primate models. NA-
1 targets intracellular protein interactions downstream of glutamate receptors, thus acting via a 
novel mechanism. Studies have demonstrated that, in addition, NA-1 does not affect the 
electrophysiological function of NMDAR channels. Therefore, unlike NMDA receptor 
antagonists, NA-1 is in a class of drugs that is not anticipated to have negative side effects that 
were ascribed to glutamate receptor antagonists.   
4.3.2 Clinical Trials 
4.3.2.1 Evaluating Neuroprotection in Aneurysm Coiling Therapy (ENACT) Trial 
To test the feasibility of neuroprotection in the human brain based on the results in the non-human 
primate microembolic stroke study described above, a Phase 2 multicentre, randomized, fasting, 
double-blind, placebo-controlled, safety, tolerability, and efficacy study evaluating a single dose 
of intravenous NA-1 was recently completed in male and female patients undergoing endovascular 
repair of brain aneurysms (unruptured and ruptured)11. The primary objectives of the trial were to 
determine the safety and tolerability of a single intravenous dose of NA-1 (2.6 mg/kg) and the 
efficacy of NA-1 in reducing the volume of embolic strokes as measured by MRI imaging. The 
secondary objectives were to determine the efficacy of NA-1 in reducing the number of embolic 
strokes; procedurally-induced vascular cognitive impairment as measured by a battery of cognitive 
tests; and the frequency of large embolic strokes.  The study consisted of one 30-day evaluation 
period.  
A total of 185 subjects were enrolled in the study; 92 were dosed with NA-1 and 93 with placebo. 
In the NA-1 treatment group, 74 subjects (80%) had unruptured aneurysms on study entry and 18 
(20%) were ruptured. The placebo group had 74 (80%) subjects with unruptured aneurysms and 
19 (20%) with ruptured aneurysms.  Six subjects (3.2%) did not complete the study: Two subjects 
died (both in the placebo group), one experienced an AE eventually leading to death (in the NA-1 
group), two were lost to follow-up (in the NA-1 group), and one was discontinued due to protocol 


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non-compliance (failed to show up for the scheduled Day 30 visit; in the placebo group).  Of 185 
randomized subjects, 184 completed the post-procedure MRI scan (12-96 hours).    
Overall, NA-1 reduced the mean number of lesions by three new lesions as evaluated by DWI 
(p=0.018) and by two new lesions as evaluated by fluid-attenuated inversion recovery (FLAIR; 
p=0.048) in comparison with placebo in All Randomized Subjects (subjects receiving any amount 
of study drug).  The distribution of the volumes of new strokes was highly skewed, and did not 
follow a normal distribution. This was anticipated based on the non-human primate model of 
microembolic stroke study10. The median lesion volume was less than 1,000 mm3. Two subjects 
with unruptured aneurysms exhibited large strokes (10,702 and 49,204 mm3 by DWI volume) as 
a result of peri-procedural complications of endovascular repair, and both were in the NA-1 group. 
In both cases the major ischemic stroke occurred several hours after the procedure. The first patient 
was neurologically well for several hours post-procedure (placement of a Pipeline stent for a giant 
cavernous carotid aneurysm) and then developed aphasia. The second patient was neurologically 
well until the morning after his procedure (balloon-assisted coiling of an internal carotid artery 
aneurysm) when he developed right hemiparesis. Both had been treated with double antiplatelet 
therapy [acetylsalicylic acid (ASA) and clopidogrel].  Due to these two outliers, there was 
sufficient distortion of the mean volume of strokes in the NA-1 group such that the analysis of the 
impact of NA-1 on mean lesion volume was neutral in the analysis of all randomized subjects and 
only subjects with unruptured aneurysms. When subjects with strokes < 10 cc were considered 
(i.e., when the two outliers were excluded from analysis), a halving of lesion volume was observed 
in patients treated with NA-1. This effect was even more evident when the results were adjusted 
for the following pre-specified covariates: age, aneurysm status, use of adjunctive devices, groin 
puncture to infusion time, and the use of antiplatelet agents (p=0.009 for DWI and p=0.014 for 
FLAIR). Among the subgroup of subjects with ruptured aneurysms, NA-1 treatment reduced the 
volume of FLAIR and DWI lesions (FLAIR: p=0.023; DWI: p=0.015) and the number of FLAIR 
and DWI lesions (FLAIR: p=0.046; DWI p=0.027).   
In terms of neurological outcomes at Day 30, there were no differences between the proportion of 
all randomized subjects with good outcomes (score of 0-1) on the NIHSS in the NA-1 and placebo 
groups at Day 30. Similarly, there were no differences between the proportion of subjects with 
independent functioning (score of 0-2) on the mRS in the NA-1 and placebo groups at Day 30. 
This was as expected because subjects that met the eligibility criteria were generally neurologically 
intact (unruptured aneurysms), or were of a good World Federation of Neurological Surgeons 
(WFNS) subarachnoid hemorrhage (SAH) grade (ruptured aneurysms). Baseline NIHSS and mRS 
scores were consistent with low levels of neurological impairment and disability (median NIHSS 
and mRS of 0), which leads to a floor effect in scale sensitivity. However, in the subjects with 
ruptured aneurysms (a subgroup with anticipated neurological impairments) treatment with NA-1 
significantly increased the proportion of subjects with a good outcome on the NIHSS versus 
placebo at the 30-day follow-up (100.0% versus 68.4%, respectively; p=0.020).  This was not 
accounted for by differences in post-treatment SAEs such as hydrocephalus, the need for cerebral 
spinal fluid diversion, or cardiopulmonary complications. 


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4.4 
Summary of Known Potential Risks and Benefits 
4.4.1 Phase 1 Study 
A Phase 1, randomized, fasting, double-blind, placebo-controlled, safety, tolerability, and 
pharmacokinetic study evaluated single ascending doses of intravenous NA-1 in healthy male and 
post-menopausal or surgically sterile female human subjects (Biovail Contract Research Study 
3301). The primary objectives of this study were to determine the safety and tolerability of single 
ascending intravenous doses of NA-1.  Sixty-two normal, healthy, non-smoking male and post-
menopausal or surgically sterile female subjects were dosed in eight cohorts. Subjects received a 
single dose of NA-1 or placebo on Day 1 of the study period, according to a randomization scheme. 
NA-1 was given as follows, with the dose increasing per cohort: 0.02, 0.08, 0.20, 0.375, 0.75, 1.50, 
2.6 and 3.75 mg/kg of active drug, given as a 10 ± 1 minute intravenous infusion.  Subjects were 
required to return on Days 7, 14 and 28 for interim and end-of-study procedures.  There were no 
SAEs; the majority of noted AEs were mild in severity; no subjects failed to complete the study 
protocol; and no subjects withdrew from the study. Forty subjects experienced a total of 168 AEs. 
Thirty-four of the 46 active treated subjects (73.9%) experienced at least one AE, while six of 16 
placebo treated subjects (37.5%) experienced at least one AE.  Of the 168 AEs, 103 were listed as 
probably related to the study drug and five AEs were possibly related to the study drug.  No severe 
AEs were reported while 160 of the 168 AEs were mild in severity and eight were moderate in 
severity. The most commonly reported AEs in subjects receiving any dose of NA-1 were flushing 
(22% of subjects), dry mouth (20%), feeling hot (20%), dizziness (17%), localized pruritis (15%), 
decreased blood pressure (BP;11%), generalized rash (9%), generalized erythema (9%), nausea 
(9%), increased blood glucose (9%), increased alanine aminotransferase (9%), oral hypoaesthesia 
(9%), paraesthesia (9%), generalized pruritis (7%), urine positive for white blood cells (7%), and 
localized rash (7%). The incidence of AEs in the 30 subjects receiving NA-1 at dose levels of 0.02, 
0.08, 0.20, 0.375, 0.75 and 1.50 mg/kg was the same as that of the 16 placebo treatment subjects. 
Subjects in the 2.6 and 3.75 mg/kg dose groups experienced more AEs than subjects in the lower 
dose groups, though none was serious.  Overall, NA-1 was well tolerated as a single intravenous 
dose in the range of 0.02 to 2.6 mg/kg, administered to healthy male and post-menopausal or 
surgically sterile female subjects.  
4.4.2 Phase 2 Study (ENACT) 
The Phase 2 ENACT study investigated the effect of a single intravenous dose of NA-1 2.6 mg/kg 
on reducing the volume and number of embolic strokes caused by the aneurysm repair procedure 
and in increasing the proportion of subjects with a good clinical outcome in 185 patients 
undergoing endovascular aneurysm coiling of unruptured or ruptured aneurysms17. In total, 724 
treatment-emergent AEs were reported in 168 (91%) of all randomized subjects.   A total of 388 
AEs were reported in 85 of 93 subjects who received placebo (91%) and 336 AEs were reported 
in 83 of 92 subjects who received NA-1 (90%). The most frequently-reported individual AEs were: 
headache, reported in 40% of placebo subjects and 46% in NA-1 subjects; nausea (29% and 36%, 
respectively), vomiting (9% and 13%), procedural pain (11% and 2%; p=0.018), and hypotension 
(6% and 10%).  Of the 388 events reported in placebo subjects, 208 (54%) were mild, 159 (41%) 
were moderate and 21 (5%) were severe.  Of the 336 AEs reported in NA-1 subjects, 187 (56%) 
were mild, 121 (36%) were moderate and 28 (8%) were severe. Of the 388 AEs reported in placebo 


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subjects, 271 (70%) were unrelated, 96 (25%) were unlikely related, 21 (5%) were possibly related 
and 0 (0%) were probably related. Of the 336 AEs reported in NA-1 subjects, 251 (75%) were 
unrelated, 72 (21%) were unlikely related, 11 (3%) were possibly related and 2 (1%) were probably 
related.  There were three deaths during this study, two in the placebo group and one in the NA-1 
group.  The SAEs leading to death were all severe and unrelated to study drug.  Other than these 
three deaths, there were no other discontinuations due to AEs.  There were 35 SAEs in 23 subjects: 
24 SAEs in 14 placebo subjects and 11 SAEs in nine NA-1 subjects.  None of the SAEs were 
assessed as related to study drug.  Overall, there were very few abnormal clinically significant 
Hematology and Biochemistry results in both treatment groups. There were no noteworthy 
differences across time between treatment groups for any of the laboratory parameters. One 
placebo subject (1%) had an elevated histamine level postdose (16 nmol/L) versus five NA-1 
subjects (5%) ranging from 10-15 nmol/L (normal range for males and females ≤ 10 nmol/L).  In 
terms of vital signs, there were no noteworthy findings in mean heart rate across time between 
treatment groups.  There were very few abnormal clinically significant 12-lead ECG results in the 
NA-1 and placebo groups.  There were no cardiac AEs that were considered to be an SAE or 
significant AE in either treatment group.  Cardiac AEs were infrequent in both treatment groups. 
Overall, NA-1 2.6 mg/kg was well tolerated and no safety concerns were identified in any of the 
patient groups. 
4.4.3 Summary of Safety of NA-1 
Overall, NA-1 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. 
4.5 
Description of and Justification for the Route of Administration, Dosage, Dosage 
Regimen and Treatment Period 
NA-1 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 and 2 clinical trials, (2) the 
observed capacity of this dose of NA-1 to reduce stroke tissue damage and to improve neurological 
function in rats and non-human primates exposed to experimental strokes when NA-1 was 
administered in animals exhibiting salvageable brain, and (3) the capacity of this dose to reduce 
stroke tissue damage and improve neurological damage in human subjects undergoing 
endovascular repair of brain aneurysms.  
4.6 
Target Patient Selection 
Inclusion/exclusion criteria of all prior neuroprotection trials aimed at selecting subject who would 
respond to the neuroprotective study drug. Preclinical evidence indicates that neuroprotection is 
aimed at salvaging brain in the ischemic penumbra, defined as that part of the ischemic brain that 
can be prevented from progressing to infarction if an appropriate treatment is given. However, due 
to the failure of all prior neuroprotection trials, it is unclear whether the prior criteria used for 
selecting responders were appropriate.  


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The ESCAPE trial provides an unprecedented opportunity for testing neuroprotectants because its 
inclusion/exclusion criteria have successfully defined a patient population in whom brain salvage 
was achievable. This is therefore a de-facto patient population which is most likely to exhibit an 
ischemic penumbra, the target for neuroprotection, at the time of initiation of endovascular 
recanalization therapy. Additionally, the high rates of reperfusion achieved with endovascular 
recanalization recapitulate ischemia-reperfusion as closely as could be achievable in clinical 
settings. Extensive preclinical data indicate that neuroprotection is (a) most effective in ischemia 
reperfusion and (b) targeted to the penumbra.  Thus it is most rational to evaluate neuroprotection 
in stroke patients who meet the ESCAPE criteria for endovascular recanalization therapy3.  
4.7 
Endovascular Acute Stroke Therapy 
Endovascular treatment for AIS has now been shown to be of clinical benefit in appropriately 
selected patients and is anticipated to become a standard of care.  Six randomized trials – ESCAPE, 
EXTEND-IA, 
SWIFTPRIME, 
REVASCAT, 
MRCLEAN, THRACE - have demonstrated the 
benefit of endovascular therapy over best medical 
management.3-7  The last of these, THRACE, has been 
presented only in abstract form.  These publications cap 
a tremendous period of clinical activity after prior trials 
of endovascular stroke therapy had been neutral or 
negative.18-20 
The trials were similar in that all the trials used CT 
angiography to identify patients with large artery 
proximal occlusions.  They differed in that ESCAPE, 
EXTEND-IA and SWIFTPRIME used multimodal CT 
imaging (multiphase CTA in ESCAPE and CTP in 
EXTEND-IA and SWIFTPRIME) to select patients. 
These latter three trials demonstrated the largest 
treatment effect size, presumably by excluding more 
patients who would have poor outcomes despite 
treatment. 
Both ESCAPE and SWIFTPRIME developed a strong 
focus on the speed of treatment.  The key messages 
from the sum of these trials are as follows: 
1) Patients must be selected with CTA to identify a
target lesions – a proximal artery occlusion.
2) Patients with very poor collaterals or very large core
infarction should be excluded because they will not
substantially benefit.  The definition of the best
imaging paradigm for patient selection continues to be debated. 
3)
Treatment must be applied very quickly.  The target interval times in ESCAPE were: CT-
to-groin puncture < 60 minutes; and CT-to-reperfusion < 90 minutes.  The ESCAPE trial


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demonstrated that median times below these thresholds were possible.  However, the 90th 
percentile times were well above these thresholds3. 
4)
High rates of reperfusion must be achieved rapidly and safely.
The strong evidence that endovascular therapy is effective in improving neurological outcome in 
patients with large vessel arterial occlusions now provides a human paradigm of the ischemia-
reperfusion model that simulates animal models of ischemia-reperfusion that are widely used in 
preclinical stroke research and in which stroke therapies, especially neuroprotectants, have been 
evaluated.  Until recently, the potential of endovascular recanalization to improve clinical outcome 
in past human trials was confounded by the failure of imaging selection, slow treatment paradigms 
and failure to fully reperfusion the brain.  It is likely that such trials included patients in whom the 
brain was no longer salvageable, or in whom arterial occlusion was longstanding. Based on 
knowledge from preclinical animal studies, it is likely that permanent ischemia models are much 
more resistant to treatment.  The results of the most recent endovascular trials now provide us with 
the opportunity to properly explore the concepts of neuroprotection and reperfusion injury and 
whether pharmacological or biological agents may allow incremental improvements in outcome 
for patients treated in this fashion.  The human paradigm will no longer be confounded by a failure 
of reperfusion and the endovascular trials have successfully defined the target patient population 
with potentially salvageable brain.  The use of NA-1 will be explored as an adjuvant agent for 
neuronal cytoprotection in the setting of AIS. 
A key benefit of this approach is that NA-1 may result in a “freezing” of the core until reperfusion 
can be achieved15.  This concept may extend to the application of treatment at distant sites to buy 
time until reperfusion therapy can be achieved.  Further, there is evidence that cellular damage 
induced by ischemia continues even after reperfusion.  This, so-called reperfusion injury, may be 
attenuated by adjuvant medical therapies such as NA-1. 
4.8 
Imaging as a Biomarker for Patient Selection 
There is consensus in the stroke research community that a treatment benefit can only accrue if the 
treatment is given to a subject with salvageable tissue-at-risk. The theoretical construct used to 
define this tissue at risk, or “penumbra” using medical imaging comprises the difference between 
imaging tissue destined for infarction and tissue that is already irreversibly infarcted (the 
“mismatch hypothesis”). Whereas the best method for imaging “mismatch” remains controversial, 
in this study we are operationally defining “mismatch” using simple CT or MRI criteria that are 
rapidly implementable and are unambiguous. These criteria aim to enroll subject with large 
volumes of tissue-at-risk based on the finding of a large arterial occlusion while exclude those with 
large core infarctions, as the latter are unlikely to benefit from endovascular therapies21. 
Based on a synthesis of past studies, we have derived the following key clinical and imaging 
criteria for selecting subject for this study: 
1) Moderate to severe ischemic stroke defined as >5 on the NIHSS.
2) No evidence of extensive infarction, defined as tissue hypodensity on NCCT scan on the
basis of Alberta Stroke Program Early CT Scan (ASPECTS) scoring system, or as
extensive apparent diffusion coefficient (ADC) restriction/DWI lesion volume (>100cc)
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3) A large arterial occlusion (carotid artery or proximal MCA) as defined by non-invasive 
imaging. 
4) Evidence of adequate pial collateral filling. 
5) Arterial occlusion amenable to safe and fast recanalization using endovascular means or 
combined intravenous thrombolysis plus endovascular treatment. 
These criteria can be met using CT scanning and the data can be gathered and interpreted in <10 
minutes.  Using the ASPECTS, extensive infarction can be excluded.  Using CTA detailed 
information can be gained on the location of occlusion and the burden of thrombus.  Further, the 
CTA (from arch to vertex) can aid the interventionist in pre-planning navigation from the aortic 
arch to the thrombus.  The pattern of collaterals is also discernible from CTA; patients with absent 
or very poor collaterals do not benefit from therapy, simply because it cannot be brought to bear 
in a timely enough fashion to prevent significant infarction. In ESCAPE3, slightly more than half 
of patients were imaged using multi-phase CTA.  Single-phase CTA and dynamic/multiphase CTA 
were used to select patients in the remaining cases.  Many sites had access to CTP imaging but did 
not use it for patient selection.  However, the pattern of collateral circulation can be assessed using 
CTP imaging. 
Thus, a fast image acquisition “good scan (small core), proximal occlusion, adequate collaterals” 
model of patient selection is being adopted. This group of patients has shown a large treatment 
effect of endovascular therapy.  This group of patients represents the near ideal “ischemia-
reperfusion” paradigm.  Thus we propose that it is the best subset of stroke patients in which to 
test the benefits of neuroprotection.  
 
 


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5 
TRIAL OBJECTIVES 
5.1 
Primary Objective 
The primary objective is to determine the efficacy of the neuroprotectant, NA-1, in reducing global 
disability in subjects with major AIS with a small established infarct core and with good collateral 
circulation selected for endovascular revascularization. 
5.2 
Secondary Objectives 
The secondary objectives are to determine the efficacy of NA-1 in: 
•
Reducing functional dependence
•
Improving neurological outcome
•
Improving activities of daily living
•
Reducing mortality rate
5.3 
Tertiary Objectives 
The tertiary objectives are to determine the efficacy of NA-1 in: 
•
Improving health-related quality of life.
•
Decreasing infarct volume at follow-up imaging
•
Improving cognitive function
5.4 
Leading Safety Objectives 
The leading 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 NA-1 to subject with acute stroke who are 
selected for endovascular revascularization on SAEs and 90-day mortality. 


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6 
TRIAL DESIGN 
This is a Phase 3 randomized, multicentre, blinded, placebo-controlled, parallel group, single-dose 
design.  Subjects harboring an acute stroke and who are selected for endovascular revascularization 
in accordance with local institutional practices and who harbor a small established infarct core and 
with good collateral circulation will be given a single, 2.6 mg/kg (up to a maximum dose of 270 
mg) intravenous dose of NA-1 or placebo as soon as they are deemed to have met the enrollment 
criteria and with the intention of starting administration within 30 minutes of randomization.  
A total of 1120 subjects aged 18 years and older will be enrolled into the study.  All subjects will 
be followed for 90 days (or until death if prior to 90 days).  Further details on the study procedures 
can be found in Table 2-1: Schedule of Assessments.  The end of study is defined as the date that 
the last enrolled subject has completed their Day 90 visit. 
6.1 
Outcomes 
6.1.1 Primary Efficacy Outcome 
The primary efficacy outcome variable for the pivotal assessment of efficacy for regulatory 
submission purposes is the overall proportion of subjects experiencing a favorable functional 
outcome 90 days post-randomization, defined as 0 to 2 on the mRS. These subjects are defined to 
be responders. 
6.1.2 Secondary Efficacy Outcomes 
The key secondary efficacy outcome is the shift of one or more categories to reduced functional 
dependence analyzed across the whole distribution of scores on the mRS at Day 90 or the last 
rating.  
Other secondary outcomes include: 
1) Proportion of subjects with good neurological outcome, as defined by a score of 0-2 on the
NIHSS at Day 90 or the last rating.
2) Proportion of subjects with functional independence in activities of daily living, as defined
by a score of ≥ 95 on the BI at Day 90 or the last rating.
3) A reduction in mortality rate, as defined by event rate (%) for mortality over the 90-day
study period
4) Proportion of subjects with functional independence, as defined by a score of 0-1 on the
mRS at Day 90 or the last rating.
6.1.3 Tertiary Outcomes 
The following tertiary outcomes will be assessed descriptively: 
1) Health-related quality of life, as measured by the EQ-5D-5L at Day 90 or the last rating.
2) Volume of stroke as measured by a) DWI and b) FLAIR at 24 Hour follow-up. If NCCT
was done instead of MRI, Volume of stroke will be derived from hypodense areas.
3) Cognitive outcomes, as measured by the 15-item Boston Naming Test (BNT15),
Sunnybrook Hemispatial Neglect Procedure (SNAP) and the Montreal Cognitive


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Assessment (MoCA). 
4) The proportion of subjects experiencing a favorable functional outcome 30 days post-
randomization, defined as 0 to 2 on the mRS.
6.1.4 Safety Outcomes of Special Interest 
The primary safety outcomes are the frequencies of SAEs and 90-day mortality. 
6.1.4.1 Guidance on Definitions of Selected Safety Outcomes 
Symptomatic intracranial hemorrhage (ICH) defined according to the Heidelberg classification, as 
a new ICH [intracerebral hemorrhage, SAH, intraventricular hemorrhage (IVH), subdural 
hematoma (SDH)] associated with clinical evidence of neurological worsening, in which, the 
hemorrhage is judged to be the most important cause of the neurological worsening.  Clinical 
worsening will be guided by the NIHSS score of a minimum of two or more points different from 
baseline. 
Major extracranial hemorrhage defined as life-threatening, resulting in hemodynamic compromise 
or hypovolemic shock, requiring inotropic support or other means to maintain cardiac output, 
requiring blood transfusion of more than two units of packed red blood cells, or associated with a 
fall in hemoglobin greater than or equal to 5 g/L. 
Contrast media-induced nephropathy will be defined as a rise of the serum creatinine of ≥ 0.5 
mg/dl (≥44 mmol/l) or a ≥25% increase from baseline pre-treatment level within 3 days after the 
endovascular procedure without an alternative etiology.  Any creatinine measurements conducted 
as part of the protocol or standard of care in the first 3 days after the endovascular procedure in 
patients suspected by their treating physician of having a contrast nephropathy will be considered 
for this adjudication. . 
Total radiation dose will be measured in mSv and recorded directly from the CT scanner.  Dose-
length product will be recorded directly from the CT scanner. 
Malignant MCA infarction will be defined as any large infarction with mass effect observed on 
imaging where treatment (medical or surgical) is required for the treatment of mass effect. 
Hemicraniectomy will be defined as that surgical procedure used to decompress the swollen 
hemisphere. 
Vessel perforation will be defined at angiography by the operator and associated with sub-
arachnoid hemorrhage. 
Iatrogenic arterial dissection will be defined at angiography by the operator. 
Arterial access site hematoma will be assessed as a complication of arterial access puncture and 
defined by clinical examination and anatomic imaging. 
Retroperitoneal hematoma will be assessed as a complication of groin puncture and defined by 
imaging (ultrasound or CTA or MR). 
Femoral neuropathy will be defined clinically and shall be considered related to the procedure if 
it is ipsilateral to the angiography puncture site and occurring with several weeks of the procedure. 


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6.2 
Randomization and Blinding 
Treatment will be assigned using 1:1 randomization (placebo:NA-1) centrally, using a web-based 
algorithm with treatment assignment allocated by web-based real-time interaction with the site. 
Randomization will be fully concealed by having both dynamic real-time allocation based upon 
random number generation and visually identical appearing NA-1 and placebo vials.  All vials will 
have a unique vial number.  
In order to minimize differences between the two treatment arms of the trial other than the 
investigational treatment, the protocol will restrict the use of multiple non-randomized intra-
arterial therapies and stratify randomization by (a) use of intravenous thrombolysis with alteplase 
(yes/no) and (b) the declared first thrombectomy approach. The intended first thrombectomy 
approach will be restricted to the use of either a stent retriever or clot aspiration device. The intent 
to use any other endovascular device type or intra-arterial medications as the initial thrombectomy 
approach constitutes an exclusion criterion. Additionally, if intravenous thrombolysis is planned 
for the subject, the intent to use any intravenous thrombolytic other than alteplase is an exclusion 
criterion.  
Thus, randomization will be stratified by declared first thrombectomy approach which will be 
dichotomized as stent retriever vs aspiration device, and by intravenous alteplase use (yes/no). 
Within each stratum, a randomized minimization procedure will occur on 6 baseline prognostic 
variables.  Subject data required for randomization are age, sex, baseline NIHSS scores, baseline 
ASPECTs score, occlusion location and site.   
The purpose of stratification is to provide increased certainty that equal or near-equal proportion 
of patients in each stratum will receive NA-1 or placebo.  
The purpose of minimization on the variables of age, sex, baseline NIHSS score, baseline 
ASPECTS score, occlusion location (MCA or ICA), and site, which are important prognostic 
variables impacting the 90 day outcome, is to balance these variables across treatments to ensure 
a reduced chance that any observed effect size of NA-1 vs. placebo is confounded by these known 
important prognostic variables. This randomized minimization method from Zhao et al, called the 
minimal sufficient balance method23, will be used to ensure that the subjects entered into the trial 
will be balanced between control and active treatment arms. Further details of the minimization 
procedure are provided in Appendix 3 – Randomization Details. 
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.  Study drug will be infused immediately after 
randomization with the intention of starting administration within 30 minutes of randomization. 
Study drug should be administered within 60 minutes of the NCCT.  
All subjects that 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 printed from the randomization website and 
it will be transmitted to the central database to create the case in the electronic case report form (e-
CRF).  The randomization date, time, the two stratification variables, tPA use, first declared device 
and the six key randomization variables, age, sex, baseline NIHSS, baseline ASPECTS, occlusion 
location and site will not be editable once the subject is randomized.  Thus, once a subject is entered 
into the randomization website, that subject’s e-CRF will be auto-created and ready for data entry. 


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The automated system will inform site staff when re-stocking of the refrigerator 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 will take place within one business day per the local participating 
site’s working practice.  
All subjects, investigators, their clinical staff, the clinical coordinating centre, the data 
management group, and the sponsor staff and delegates will 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 a group that is independent of the sponsor and blinded project team 
implementing the trial. A firewall will be maintained between the IDMC (unblinded) and the 
project staff (blinded). 
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 in the event that unblinding is necessary 
(Section 6.3). This individual will not participate in data management and will only communicate 
unblinded data as set out below when contacted by the medical monitor.  
6.3 
Procedure for Breaking the Randomization Code 
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.  The Investigator is 
requested to maintain the blind as far as possible. If at all possible, the actual treatment allocation 
should not be disclosed to the subject and/or other site personnel unless, in the judgement of the 
investigator, this information is required for the subject’s safety. The actual treatment allocation 
must not be disclosed to study personnel on site not involved in the subject’s medical care, to 
monitors or the sponsor.  The investigators have the final decision and unilateral right for 
unblinding. 
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 ESCAPE-NA1 CRU centre to request unblinding of the specific 
subject. The CRU 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 an 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 files.  
In order to fulfill expedited regulatory reporting requirements, the Sponsor may be required to 
unblind the subject if the SAE meets the criteria for reporting to health authorities.  The Medical 
Monitor or Drug Safety Manager will initiate the request that the subject’s treatment group be 


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unblinded.  In this case, the code will be broken only for the subject(s) in question. The information 
resulting from code-breaking (i.e., the subject’s dose assignment) will not be communicated to 
either the Investigator or any other clinical team member of the Sponsor. 
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. 
6.4 
Treatment 
6.4.1 Dosage Form, Accountability and Labeling 
NA-1 was formulated at 20 mg/ml under current Good Manufacturing Practices by The University 
of Iowa College of Pharmacy in 50 mM sodium phosphate buffer with 0.45% sodium chloride 
(NaCl), potential hydrogen (pH) 7.0.  This formulation was dispensed aseptically into 30 mL vials 
with snap cap lids (13.5 mL) intended for a single-dose intravenous injection of NA-1.  
Placebo consists of the same buffer used for NA-1 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). 
Formulated NA-1 and placebo will be delivered in sterile, single-use individually labeled vials 
(serum vials) each with a unique five-digit identification number each with a unique five-digit 
identification number, and will be stored at the clinical site at 2 to 8°C in a secure location with 
restricted access. 
Records will be made of the receipt and dispensing of the study drugs supplied.  Documentation 
for each study drug will include, but may not be limited to, the following information: 
1) Receipt date
2) Description of drug package, and drug product
3) Lot/Batch/Five-digit Code
4) Expiry and/or Manufacturing and/or retest date
5) Dispensing information.
Drug vials will be labeled in accordance with applicable regulatory requirements. 
6.4.2 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 recorded on the label or source document (value in mL).  Vials labeled as 
“used” will be retained in a separate storage container than the unused vials, and will be shipped 
to a location specified by the sponsor, upon the sponsor’s request. Used vials will be disposed of 
on site, once the CRA has completed the study drug monitoring.  Unused vials will be returned to 
the sponsor or disposed of on site after they have been monitored by the sponsor or sponsor’s 
representative. Destruction of unused vials on site will be documented and conducted in 
accordance with the site’s procedures.  


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6.5 
Study Drug Monitoring 
At each applicable monitoring visit, the monitor will verify that: 
•
Study drug vials are appropriately stored in the refrigerator at 2 to 8 °C in a secure location,
and that they have the correct expiry date
•
CT area refrigerators are being re-stocked in a timely fashion
•
Dose volume, start and stop time, and subject weight are recorded after each randomization
•
Any expired, lost, damaged or out-of-specification medication has been properly reported
and documented, and follow-up has been conducted
6.6 Case Report Forms 
All source documentation will be reviewed for compliance with GCP.  Case report forms (CRF) 
for the study are electronic. 
6.7 
Process, Timing and Quality Assurance Metrics 
To ensure that the process and quality of key activities related to randomization, drug dosing and 
thrombectomy procedures and patient follow up are in place, process (including timing) and 
quality assurance metrics will be followed on an ongoing basis throughout the study by 
reviewing data collected in the CRF.  The metrics that will be followed include: 
1) Time from randomization to start of study drug administration (<30 min)
2) Time of Drug infusion start to drug infusion completion (10 ± 1 minutes)
3) Time of stroke onset to time of study drug infusion start
4) Time of stroke onset to reperfusion
5) Time of start of study drug administration to reperfusion
6) NCCT-to-study drug initiation time (<60 min)
7) NCCT-to-groin puncture time (“picture-to-puncture”) (<60 min)
8) NCCT-to-recanalization time (“picture-to-reperfusion”) (<90 min)
9) Rate of aspiration pneumonia
10) Rate of use of general anesthesia
11) Rate of symptomatic deep venous thrombosis/pulmonary embolism
12) Proportion of subject with any SAE per site
13) Fidelity of primary thrombectomy device intended for use versus primary thrombectomy
device actually used.


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7 
SELECTION AND WITHDRAWAL OF SUBJECTS 
7.1 
Study Enrolment Process 
Subjects will be identified using usual standard of care screening methods at the acute stroke 
hospital.  This will include screening by neurology residents, fellows, nurse practitioners, 
physician assistants or faculty physicians.   
Sites will only be selected to participate in the study if they have established mechanisms for 
screening this population of subject.  This includes standard of care use of NCCT and CTA. 
All subjects will undergo an acute clinical assessment, blood laboratory assessment and baseline 
brain imaging. For the standardization of the imaging criteria for patient selection across sites, all 
sites will perform a NCCT brain and CTA to determine patient eligibility.  The NCCT head will 
be assessed using ASPECTS (Alberta Stroke Program Early CT Score) prior to randomization. 
Patients with an ASPECTS score of 5 or greater may be included in the study.  ASPECTS is a 
reliable and reproducible assessment tool with low inter- and intra-observer variability22 and is 
used to standardize the imaging criteria used for patient selection.  The CTA will be also assessed 
for collateral status using a collaterals scoring system similar to that used for patient selection in 
the ESCAPE trial.  Instructions for the determination of the ASPECTS score and collaterals 
scoring on CTA are provided in Appendix 2: Derivation of ASPECTS on NCCT and Collaterals 
Scoring on CTA and additional details can be found at  www.aspectsinstroke.com.  
From the perspective of imaging to recanalization and other interval times, the first slice of the 
baseline NCCT is when the timing begins.  
If CTP is done routinely at the site, NCCT and CTA must still be used to determine inclusion 
criteria.  It is mandated that a CTP cannot be performed before the CTA. 
In order to track the potential for enrolment, each enrolling site will provide the total number of 
patients admitted to that site with the diagnosis of AIS. Individual patient screening logs will not 
be required. 
If the subject remains eligible after completion of routine screening, the patient will be consented 
(as required) and enrolled into the study.  A patient who consents but is not randomized will be 
considered a screen failure. A subject is considered randomized the moment the randomization 
process is completed on-line.  This is time “0” for the study.  Subjects who are randomized but do 
not receive study drug will still be followed through the 90-day study period.  
7.2 
Inclusion Criteria 
1) Acute ischemic stroke (AIS) for immediate endovascular treatment.
2) Age 18 or greater.
3) Onset (last-seen-well) time to randomization time within 12 hours.
4) Disabling stroke defined as a baseline NIHSS > 5 at the time of randomization.
5) Pre-stroke (24 hours prior to stroke onset) independent functional status in activities of daily
living with modified Barthel Index (BI) > 90 (95 or 100).  Patient must be living in their own
home, apartment or seniors lodge where no nursing care is required.


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6) Confirmed symptomatic intracranial occlusion, based on multiphase or dynamic CTA, at one
or more of the following locations: Intracranial, carotid T/L, M1 MCA.  Anterior temporal
artery is not considered an M2.  Functionally, when defining the M1 MCA, the bulk of the
MCA territory must be ischemic.
7) Non-contrast computed tomography (NCCT) and CTA* for trial eligibility performed or
repeated at ESCAPE-NA1 stroke centre with endovascular suite on-site.
8) Endovascular treatment with declared first endovascular approach as either stent retriever or
clot aspiration device, and intended to be initiated (arterial access) within 60 minutes of
baseline/qualifying NCCT with target baseline/qualifying NCCT to first recanalization of 90
minutes.  Study drug intended to be administered within 60 minutes of the baseline/qualifying
NCCT.
9) Signed informed consent from subject or legally authorized representative or, if required to
enable inclusion by applicable national laws and regulations and the applicable independent
review boards/Ethics Committee requirements for obtaining consent, from the investigator
after consultation with an independent physician who is not otherwise participating in the trial.
*As per the List of Abbreviations (Section 1.2), all references to CTA indicate a multiphase or
dynamic CTA.
7.3 
Exclusion Criteria 
1) Evidence of a large core of established infarction defined as ASPECTS 0-4.
2) Evidence of absence of collateral circulation on CTA (Collateral score of 0 or 1).
3) Intent to use any endovascular device other than a stent retriever or clot aspiration device or
intra-arterial medications as the initial thrombectomy approach.
4) Intent to use any intravenous thrombolytic other than alteplase if intravenous thrombolysis is
planned.
5) No femoral pulses, very difficult endovascular access or extreme tortuosity of the great vessels
that is predicted to result in an inability to timely deliver endovascular therapy.  Direct common
carotid or radial/brachial/axillary access is permissible.
6) Estimated or known weight > 120 kg or < 45 kg.
7) Pregnancy; if a woman is of childbearing potential a urine or serum β-hCG test is positive, or
breastfeeding.
8) Severe contrast allergy or absolute contraindication to iodinated contrast preventing
endovascular intervention including any contraindications listed in the prescribing information
approved by local authorities (e.g., patients with decompensated heart failure as a
contraindication for the use of VISIPAQUETM 270 in Germany).
9) Clinical history, past imaging or clinical judgment suggests that the intracranial occlusion is
chronic or there is suspected intracranial dissection such that there is a predicted lack of success
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10) Prior enrolment in the ESCAPE-NA1 trial or prior receipt of NA-1 for any reason.
11) Severe known renal impairment defined as requiring dialysis (hemo- or peritoneal) or if known
creatinine clearance < 29 mL/min.
12) Patient has a severe or fatal comorbid illness that will prevent improvement or follow-up.
13) Patient cannot complete follow-up treatment due to co-morbid non-fatal illness or they are a
visitor to the city or any other known reason that follow-up would be impossible (e.g.
incarcerated in a federal prison).
14) Participation in another clinical trial investigating a drug, medical device, or a medical
procedure in the 30 days preceding study inclusion.
This population is expected to consist of subject very similar to those treated in the ESCAPE trial.3 


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8 
TREATMENT OF SUBJECTS 
8.1 
Study Interventions 
Patients who are deemed to be candidates for endovascular intervention in accordance with the 
inclusion/exclusion criteria will be randomized to receive NA-1 or placebo.  
8.1.1 Administration of Study Drug 
8.1.1.1 Timing of Dose Administration  
The enrolling specialist will determine if the patient is a candidate for endovascular reperfusion 
based in the study inclusion/exclusion, consent has been obtained and randomization allocation 
has occurred.   
At the time that a patient is deemed to be eligible for endovascular recanalization, the research 
coordinator (or delegate) will log into the central randomization website, enter key variables, and 
the website will inform which of the vials in the refrigerator should be used for that subject based 
on the current balance in the trial assignment of the baseline characteristics of all subjects 
randomized to date.  The research coordinator (or delegate) will then select that single vial of study 
drug from the refrigerator and prepare it for administration. 
Dose timing shall start at the time of drip onset.  Study drug is intended to be administered within 
60 minutes of the NCCT and within 30 minutes of randomization. The time of dosing onset and 
the time at which the endovascular angiographic procedure began (insertion of an angiogram 
sheath into the femoral (or other relevant) artery at the start of the procedure) will be recorded on 
the CRF. 
8.1.1.2 Dose Administration 
Dosing will be carried out by, or under the supervision of, the trial physician who is supervising 
the care of the subject for the planned or ongoing endovascular reperfusion procedure.  
A syringe for each individual subject dosing will be prepared by calculating the volume to draw 
from the vial as follows: for subjects weighing less than 105 kg: (2.6 mg/kg x subject weight in 
kg)/(20 mg/ml).  This will determine the number of mL to pull up into the syringe.  For subject 
weighing 105-120 kg the full volume of one vial (13.5mL, equivalent to 270 mg of NA-1) will 
be used.  
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 and 
subject’s age.  The bag will be mixed by squeezing and inverting the bag several times.  After 
dilution into the drip bag, the drug is stable for up to 5 hours, however it should be infused into 
the subject as soon as practical with a target randomization to treatment time of 30 minutes or 
less.   
An appropriate sized syringe must be used, such that this volume is between 20% and 100% of 
the delineated markers on the syringe.   Once a volume of drug has been drawn into the syringe, 
the vial will be marked as “used” and placed into a separate vial storage area. 


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Dosing will be performed by administering the contents of the bag of study drug to the subject 
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 while 
the intravenous bag contents are administered to the subject. The entire volume (treatment dose) 
of the intravenous mini-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.  This method 
of dose administration is identical to that previously conducted in the Phase 2 ENACT trial11. In 
the event that a subject is concomitantly receiving alteplase therapy, dose administration of NA-1 
will be conducted through a separate intravenous catheter inserted into an extremity not containing 
the alteplase line. If alteplase therapy has been completed, the same intravenous catheter may be 
used after it has been flushed with saline. 
8.2 
Interventions 
8.2.1 Endovascular Intervention 
The neuro-interventionalist will pre-declare, prior to randomization, their preferred first 
endovascular device type to be used in the procedure, defined as either a ‘stent retriever 
thrombectomy’ or ‘aspiration thrombectomy’. Any currently available and approved/cleared 
device may be used for this purpose.  The neuro-interventionist should adhere to using this declared 
device when making their first approach. If the first approach fails, the neuro-interventionalist may 
use their best medical judgment to complete the procedure in the patient’s best interest. The use of 
a balloon guide catheter is recommended with the stent retriever approach. 
Any use of an intra-arterial medication such as a thrombolytic agent (eg. alteplase) or antiplatelet 
agent is known to be uncommon and will be recorded in the concomitant medications list.  
Permanent stents should not be left in the intracranial circulation or in the internal carotid artery, 
except under exceptional circumstances dictated by the needs of acute patient care.  
Guidance for recommended approaches to endovascular revascularization are provided in 
Appendix 1 – Guidance on Imaging Selection and Endovascular Treatment. 
8.2.1.1 Acute Carotid Artery Stenting 
It is recommended that carotid artery stenting should not be undertaken acutely in order to avoid 
the need for dual antiplatelet agents.  It is strongly recommended that neuro-interventionists tackle 
the intracranial occlusion primarily and only then consider the extracranial carotid artery.  In some 
circumstances, carotid angioplasty, without stenting may be required with a planned return to the 
neuro-intervention suite 2-3 days later for definitive carotid management with stenting.  It is 
recognized that carotid artery stenting may still be required in some circumstances.  The use of 
carotid artery intervention (angioplasty with or without stenting) will be monitored and specific 
data collected.  
8.3 
Guidelines-based Medical/Stroke Unit Care 
All acute stroke subjects should receive the best standard of care according to national guidelines. 
The model will be the Canadian best practices guidelines for acute stroke care.  These are very 


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similar to the guidelines of the American Stroke Association and the European Stroke 
Organization.  All subjects are expected to be admitted to hospital as part of routine standard of 
care.  
It is expected that all subjects will undergo a routine work-up for the mechanism of their stroke 
and be treated appropriately and definitively.   This is critically important because subjects who 
have an excellent early recovery are at the highest risk of early recurrent stroke.24  We wish to 
prevent recurrent stroke from confounding the 30-day and 90-day clinical outcome such that 
subject who are well at discharge remain that way for the duration of the 90-day follow-up period. 
We expect the following preventive care.  Relevant subject with atrial fibrillation should be anti-
coagulated.  Patients with symptomatic carotid artery stenosis should undergo carotid 
revascularization early and definitely within two weeks of stroke onset.25  Risk factors, including 
hypertension, elevated cholesterol, diabetes mellitus, tobacco smoking, should be treated 
appropriately and aggressively according to current standards of care. 
We expect subjects to receive adequate hydration to prevent renal complications.  Patients will 
receive intravenous radio-contrast media for CTA for endovascular intervention.  While these 
medications are generally extremely safe in stroke patients,26 simple hydration can prevent renal 
complications, particularly among patients with baseline borderline renal function and among 
those with diabetes mellitus.  Further, patients with ischemic stroke are generally slightly 
hypovolemic at baseline.  We recommend use of intravenous normal saline (0.9% saline) infusion 
at 1.5 – 2.0 cc/kg/h until the subject is eating and drinking safely and well.   Therefore, for the 
typical subject this will mean intravenous normal saline at 75-125 cc/h overnight only.  We do not 
recommend the use of bicarbonate solutions or N-acetyl-cysteine solutions for renal protection.27,28  
In general, the risk of nephrotoxicity from modern non-ionic, iso-osmolar radiocontrast media is 
extremely low. 
For subjects that are disabled from their stroke and require a longer in-patient stay and/or 
rehabilitation, it is expected that they will receive standard stroke unit care to prevent 
complications.  These include: 
•
Deep vein thrombosis (DVT) prophylaxis for subject who are bed-bound or primarily
bed-bound
•
Swallowing assessments and prevention of aspiration pneumonia
•
Early mobilization and physiotherapy to prevent skin breakdown, pneumonia,
DVT/pulmonary embolism beginning 24 hours after randomization
•
Early diagnosis and treatment of fever
All subjects are expected to receive expert stroke unit care and then rehabilitation according to 
their clinical need.  
In brief, it is expected that: 
1) Patients who are appropriate candidates for intravenous thrombolytic therapy within 4.5
hours of defined stroke onset to get rapidly administered intravenous alteplase therapy.
2) All subjects should be managed urgently with attention to physiology.  Airway, breathing
and circulation (ABC) first.  Fluids – usually normal saline - should be administered, as


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most patients are slightly hypovolemic.  BP should not be aggressively treated other than 
to guidelines to allow thrombolytic therapy. 
3) All subjects should be managed on a stroke unit which should include early mobilization,
early rehabilitation, DVT prophylaxis, swallowing assessment and prevention of aspiration
pneumonia, nasogastric (NG) feeding as appropriate and delayed (up to four weeks)
placement of percutaneous endoscopic gastrostomy (PEG) tubes in the uncommon instance
that these are needed.
4) All subjects should receive ASA therapy (minimally) within the first 48 hours of stroke but
after a day plus one brain image showing no evidence of major hemorrhage.
5) Patients should not receive intravenous unfractionated heparin.
6) All subjects should be thoroughly investigated to sort out the mechanism of stroke and
appropriate stroke prevention strategies implemented.  There is little use in working very
hard on a technical and aggressive approach to acute stroke if it is to be undone on day +10
with a recurrent embolus because a subject has not been effectively treated for a
preventable cause of stroke.
7) All subjects should have relevant and appropriate stroke rehabilitation therapy including
physical, occupational and speech therapy.
In summary, it is expected that all subject should have excellent, guideline based stroke care 
through the full 90 days. 
8.4 
Speed of Intervention 
A key principle of the neuroprotective and endovascular intervention is that it must be both fast 
and safe.  The target NCCT to revascularization time is the 90th percentile < 90 minutes and median 
at 75 minutes or less.  Similarly, an interim measure will be the NCCT to groin puncture time at 
90th percentile of <60 minutes and median at <45 minutes.  This will be measured from the time 
of the first slice of the baseline/qualifying NCCT head done at the ESCAPE-NA1 centre.  The 
target complication rate is less than 1%.  The quality of intervention will be ensured by hand-
selection of sites and only be approved by the executive committee after a site visit.  All sites will 
be selected from the ESCAPE trialists.  New sites must submit evidence within the two years prior 
to commencement of the trial that they can meet the 90-minute target of CT-to-recanalization time.  
For sites that participated in the ESCAPE trial, their trial data will constitute proof of capability of 
treatment. A principle of the evaluation of neuroprotection by NA-1 is that it should be 
implementable without significantly delaying the subject’s access to reperfusion. 
A key and critical component of the trial will be an ongoing quality assurance program to ensure 
that sites can meet these targets for endovascular intervention.  Training will be undertaken at the 
sites and continued on a quarterly basis.  Monitoring of interval times will be collated and provided 
to sites on a quarterly basis so that regular feedback might induce appropriately fast treatment 
processes.  Sites that fail to meet these objectives in the trial will be dropped from the trial. 
The sites will be assisted to achieve these targets. 
8.5 
Consent Process 
Signed informed consent will be obtained prior to any protocol-specific procedures from the 
subject or legally authorized representative or, if required to enable inclusion by applicable 


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national laws and regulations and the applicable independent review boards/Ethics Committee 
requirements for obtaining consent, from the investigator after consultation with an independent 
physician who is not otherwise participating in the trial. 
If the original process involved anyone other than the subject , and if required by local standards, 
consent will be sought for the remaining procedures from the subject once they are deemed to have 
regained capacity. 
8.6 
Baseline Clinical and Laboratory Evaluations 
At Baseline, all subjects will undergo a routine neurological and clinical assessment (including 
history, examination and vital signs), the NIHSS and pre-stroke BI.   
Emergency blood work will be drawn including: CBC (hemoglobin, platelets and hematocrit), 
electrolytes (sodium, potassium, chloride), INR, aPTT, serum creatinine and serum glucose.  The 
study will use and collect local laboratory results and will not use a central lab.  The results of this 
blood work are not required prior to randomization. 
If the subject is female and is of childbearing potential a pregnancy test (urine point-of-care 
pregnancy test) must be completed and the result must be negative; this is the only mandatory 
laboratory test prior to randomization. Other laboratory or point-of-care testing may be performed 
at the discretion of the attending physicians and team.   
An ECG should be completed at baseline. If the treating physician deems that a baseline ECG 
impedes the patient’s access to timely care, the ECG must be performed within 6 hours of 
randomization. 
All prior medications taken within three days of treatment initiation will be recorded on the e-CRF. 
8.7 
Immunogenicity Substudy 
Plasma samples for immunogenicity analysis will be collected at Day 1 and Day 30 from up to 
250 subjects enrolled at a subset of sites in Canada and the US. 
8.7.1 Immunogenicity Sample Collection 
At Day 1 (24 hours post dose – a time when no significant quantities of NA-1 remain in the 
blood) and Day 30 a 5 mL sample of blood will be collected in tubes provided by the 
Sponsor.  Sample collection method should be the least invasive to the subject and may be 
combined with routine blood sampling.  
The samples will be handled per guidelines/instructions provided by the sponsor.  These tubes 
are labeled with adhesive labels that identify the study code, site number, the subject’s number, 
and the sample Day.  A minimum of 1.0 mL of plasma will be transferred into each cryovial.   
The date and time for each step (blood draw, storage, centrifugation, aliquoting, and freezing) 
and the number of aliquots obtained must be documented in the source document. 


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8.7.2 Immunogenicity Sample Storage and Shipment 
During storage, plasma tubes are to be kept in a freezer at -10°C or colder. The temperature will 
be monitored and documented for the duration of any sample storage. 
Plasma will periodically be shipped frozen to the sponsor.  Further shipping instructions will be 
provided by the Sponsor. 
8.8 
Pharmacokinetics Substudy 
In order to assess Pharmacokinetics in the patient population, 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.  
8.8.1 PK Sample Collection 
A total of six 2 mL blood samples for PK assessment will be drawn during the Baseline Visit.  
Time (T) =0 being the initiation of dosing of study drug or placebo.  Samples will be drawn at the 
following timepoints: 
• Sample 1: post randomization & prior to start of study drug administration (Time=0 min)
• Sample 2: 10 minutes from start of study drug administration (Time = 10 min)
• Sample 3: 20 minutes from start of study drug administration (Time = 20 min)
• Sample 4: 30 minutes from start of study drug administration (Time = 30 min)
• Sample 5: 60 minutes from start of study drug administration (Time = 60 min)
• Sample 6: 120 minutes from start of study drug administration (Time = 120 min)
At each timepoint a 2 mL sample of blood will be collected in tubes provided by the 
Sponsor.  Sample collection method should be the least invasive to the subject and may be 
combined with routine blood sampling.  
The samples will be handled per guidelines/instructions provided by the sponsor.  These tubes 
are labeled with adhesive labels that identify the study code, site number, the subject’s number, 
and the sample date and time.  A minimum of 1.0 mL of plasma will be transferred into each 
cryovial.   
The date and time for each step (blood draw, storage, centrifugation, aliquoting, and freezing) 
and the number of aliquots obtained must be documented in the source document. 
8.8.2 PK Sample Storage and Shipment 
During storage, PK tubes will be kept in a freezer at -10°C or colder. The temperature will be 
monitored and documented for the duration of any sample storage.  PK samples will be stored in 
a separate cryobox from immunogenicity samples.  All samples taken from the same subject 
should be stored in the same cryobox. 
PK samples will be periodically shipped frozen to the Sponsor. Further shipping instructions will 
be provided by the Sponsor prior to study start up. 


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8.9 
Brain and Neurovascular Imaging 
All subjects will initially undergo rapid NCCT and CTA imaging. Routine NCCT and CTA 
imaging guidance and minimal acceptable criteria for image quality are provided in Appendix 2: 
Derivation of ASPECTS on NCCT and Collaterals Scoring on CTA.  Sites that did not participate 
in the ESCAPE trial will submit sample images to the core lab for quality assessment. 
The use of a dynamic CTA or multiphase CTA data acquisition protocol is mandatory for 
ESCAPE-NA1. This is detailed in Appendix 2: Derivation of ASPECTS score on NCCT and 
Collaterals Scoring on CTA.  
Baseline NCCT and CTA may be completed at a hospital affiliated with the ESCAPE-NA1 stroke 
centre, only if the baseline NCCT to drug delivery time < 60 minutes and the appropriate NCCT 
and multiphase/dynamic CTA are completed at the affiliated hospital provided that the imaging 
studies are available in the same medical imaging network.   
Imaging at follow-up (24h) which will be used to assess infarct volumes, will be conducted using 
MR. 
Thus, imaging and imaging assessments will be fully standardized for all assessments. 
For all interval times assessed from imaging, the time zero will be the first slice of the NCCT scan.  
The purpose of this approach is to include imaging time and post-processing time in to any time 
metric. 
8.10 Study Drug Administration 
Dosing will begin as soon as the enrolling specialist has indicated that the subject is a candidate 
for endovascular reperfusion based in the study inclusion/exclusion, consent has been obtained 
and randomization allocation has occurred.  See Section 8.1 for additional details. 
8.11 Evaluations Following Randomization 
Vital signs will be completed pre- and post-dose and at 24 and 48 Hours, and Day 5.  An ECG will 
be completed at 24 ± 12 Hours.  Blood tests will be conducted at 24 ± 12 Hours including: CBC 
(hemoglobin, platelets and hematocrit), electrolytes (sodium, potassium, chloride), INR, aPTT, 
serum creatinine and serum glucose. 
All subjects will undergo a follow-up brain MRI [including a minimum of axial DWI, gradient-
echo (GRE), FLAIR] at 24 ± 12   Hours from the time of randomization.  The 24-hour MR is 
considered a standard of care imaging procedure; if MR is unavailable, then NCCT is allowed. 
All subjects will have a mRS scale scores evaluated at Day 5 or discharge, Day 30, and Day 90.  
Additionally, a pre-morbid (baseline) mRS will be collected and recorded on the 24h CRF page.  
All subjects will also undergo a NIHSS assessment at 2 Hours (end of the angiogram procedure), 
24 and 48 Hours, and Day 5 or discharge, 30, and 90.  The BI will be completed at Day 30 and 90 
days. The EQ-5D-5L will be completed at Day 30 and 90 days. 
Mortality and discharge disposition will be assessed at Day 5 or discharge.  Mortality will also be 
assessed at Day 30 and 90. Then BNT, SNAP and MoCA will be conducted at Day 90. 


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SAEs will be collected through to Day 90.  AEs and concomitant medications will be collected to 
Day 30.   All time windows are calculated from the time of randomization (time ‘0’). 
8.12 Imaging 
The baseline NCCT and CTA and all brain imaging conducted within the first 48 hours thereafter 
will be rendered anonymous and sent to the ESCAPE-NA-1 core lab (Calgary) for central 
adjudication.  The 24 hour MR (and where MR is unavailable, CT) will be used to assess 24 Hour 
infarct volume, an exploratory tertiary outcome. Other brain imaging will be sent only if requested 
by the adjudication committee. 
The core imaging lab staff will review all imaging for the acute stroke intervention period as per 
an Imaging Adjudication Charter in order to ensure adherence to the imaging guidelines and 
enrollment criteria, to determine reperfusion rates and quality of the intervention, and safety. 
Infarct volume determinations (an exploratory outcome) will not be conducted until after database 
lock.  
8.13 Criteria for Discontinuation from the Study 
Participation in this clinical study may be discontinued for any of the following reasons: 
•
Administrative reasons (uncooperative, noncompliant, etc.)
•
Subject’s decision not to participate any further
•
If it is in the subject’s best interest, per the qualified/principal or sub-investigator
If the subject or legally authorized representative (LAR) withdraws consent, subject 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 e-CRF.  
If the LAR has originally provided consent and the subject 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 subject may not withdraw use of his or her data that have already been collected, this is in 
alignment with the FDA guidance document FDA 21 CFR UCM126489, Data Retention When 
Subjects Withdraw from FDA-Regulated Clinical Trials29 which states: “FDA recognizes that a 
subject may withdraw from a study; however, the withdrawal does not extend to the data already 
obtained during the time the subject was enrolled. FDA’s longstanding policy has been that all 
data collected up to the point of withdrawal must be maintained in the database and included in 
subsequent analyses, as appropriate”. 
Otherwise, all randomized subjects will continue to be followed according to protocol 
requirements and follow-up data will be included in the analysis.  Criteria for removal of subjects 
will be recorded and reported. 
In the event a subject is lost-to-follow up, all efforts made by the research coordinator to bring the 
subject in for a clinic visit for follow-up and this process will be documented. 


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9 
ASSESSMENT OF EFFICACY 
For the assessment scales listed below, sites and local investigators will be responsible for 
obtaining certification prior to conducting any assessments.  
9.1 
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
stroke30,31. mRS scores range from 0 to 6, with 0 indicating no residual symptoms; 5 indicating
bedbound, requiring constant care; and 6 indicating death.
The mRS will be obtained at Day 5 (or discharge), Day 30 and 90.  Premorbid mRS status will 
also be obtained retrospectively and reported on the 24h CRF page.  The mRS will only be scored 
by those trained and certified in the use of this scale.   
9.2 
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 stroke32.  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), at 24 and 48 Hours, Day 5 or discharge, 30 
and 90. The NIHSS will only be scored by those trained and certified in the use of this scale.  
9.3 
Barthel Index 
The BI is an index of functional independence33 that is a valid measure of activities of daily living 
when employed in stroke trials34.  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), on Day 30 and 90 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. 
9.4 
Mortality Rate 
Mortality rates are defined as the number of deaths observed divided by the number of subject 
observed over the 90-day study period. 
9.5 
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/Depression35. Each dimension has five response 
categories corresponding to: no problems, slight, moderate, severe and extreme problems36. The 
instrument is designed for self-completion, and respondents also rate their overall health on the 


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day of the interview on a 0–100 hash-marked, vertical visual analogue scale (EQ-VAS). The EQ-
5D-5L will be administered on Day 30 and 90 by those trained in the use of this scale. 
9.6 
Volume of Strokes 
After database lock, the total volume of new a) DWI and b) FLAIR lesions in NA-1 versus placebo 
control subjects will be calculated from the 24-hour imaging. Where MR is not available, infarct 
volumes will be determined from the 24-hour CT scan. The plan for combining CT and MRI data 
will be detailed in the imaging adjudication charter.  
9.7 
Cognitive Outcomes 
The BNT15 is a widely used neuropsychological assessment tool to measure confrontational word 
retrieval in individuals with aphasia or other language disturbance caused by various neurological 
disorders.37 
The SNAP is a short bedside battery for visuoconstructive hemispatial neglect shown to be a 
highly reliable and valid instruments with good internal consistency in stroke subject.38 
The MoCA (www.mocatest.org) has been found to be a feasible global cognitive screening tool in 
stroke trials39. It has been found to be sensitive in detecting post-stroke cognitive impairment; raw 
scores using the published cut-off score of 26 showed good sensitivity but moderate specificity. 
Montreal Cognitive Assessment scores adjusted for age and education provide both good 
sensitivity and very good specificity.40  
The BNT15 (short form)41, SNAP and MoCA will be administered at Day 90 by those trained in 
the use of these scales.  Assessments will only be conducted if the tool/scale is available in the 
local country language.  If the assessment is not conducted for language reasons the outcome will 
not be measured for those subjects. 
9.8 
Pharmacokinetics Assessment 
Actual sampling time-points will be recorded and used for PK calculations. If data permit, the 
following PK parameters for NA-1 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 NA-1 will be excluded from analysis (placebo).  A further analysis of 
the effect of administration of thrombolytic therapy (alteplase) on the pharmacokinetics of NA-1 
will also be performed. 
9.9 
Additional Assessments 
Two key concepts will also be explored in this trial: 


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1)
The addition of a neuroprotectant to endovascular revascularization is feasible and can be
done with a CT to Thrombolysis in Cerebral Infarction Score (TICI)3 flow in < 90
minutes.
2)
Feasibility of recruitment rate, defined by the recruitment in this multisite trial.


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10 ASSESSMENT OF SAFETY 
10.1 Adverse Event Definitions 
The following definitions are taken from the ICH E2A Guideline for Clinical Safety Data 
Management: Definitions and Standards for Expedited Reporting. 
Adverse Event: 
An AE is any untoward medical occurrence in a patient or clinical investigation subject 
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.  
Therefore, an AE may be: 
•
A new illness
•
The worsening of a concomitant illness
•
An effect of vaccination, including the comparator
•
A combination of the above
All AEs include serious and non-serious AEs. 
Pre-existing medical conditions are not to be reported as AEs. However, if a pre-existing condition 
worsens in frequency or intensity, or if in the assessment of the treating physician there is a change 
in its clinical significance, this change should be reported as an AE (exacerbation). This applies 
equally to recurring episodes of pre-existing conditions (e.g., asthma) if the frequency or intensity 
increases post-randomization. 
Serious Adverse Event: 
Serious and severe are not synonymous. The term "severe" is often used to describe the 
intensity (severity) of a specific event (as in mild, moderate, or severe myocardial infarction); the 
event itself, however, may be of relatively minor medical significance (such as severe headache). 
This is not the same as "serious," which is based on patient/event outcome or action criteria usually 
associated with events that pose a threat to a patient's life or functioning. Seriousness (not severity) 
serves as a guide for defining regulatory reporting obligations.  
A serious adverse event (or reaction) is any untoward medical occurrence that at any dose: 
1) Result in death
2) Are life-threatening
3) Require or prolong inpatient hospitalization
4) Result in persistent or significant disability/incapacity, or
5) Are a congenital/birth defect
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 subject and may require medical or surgical 
intervention to prevent one of the outcomes listed in this definition. For example, any new 


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diagnosis of cancer (made after study enrollment) is considered an important medical event. 
Because our primary safety outcomes for the trial are also SAEs by definition, they will be reported 
dually as SAEs and as outcomes.  SAEs should be managed according to the best current standard 
of care. 
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. 
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 products" 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. 
AE occurring within 30 days of randomization and all SAEs will be reported in the CRF.  Severity 
and relationship definitions are presented below. 
Table 10-1: Definitions of AE-Related Terms 
AE Severity 
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. 
AE 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. 
Probably: 
A clinical event, including laboratory test abnormality, with a reasonable 
time sequence to drug administration, unlikely to be attributed to concurrent 
disease or other drugs or chemicals, and which follows a clinically 
reasonable response on withdrawal. 
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. 


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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).  
10.2 Clinical Management of Adverse Events 
10.2.1 Early Study Drug Cessation 
The intervention is the intravenous administration of 2.6 mg/kg (up to a maximum of 270 mg) of 
NA-1 over a 10 ± minute intravenous infusion to subject 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. 
If any SAE is observed during dosing, dosing shall be immediately terminated.  If any moderate 
or severe AE is observed, the physician may terminate drug administration at his/her discretion. 
10.2.2 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 subject, the hospital physician will be instructed, at his/her 
discretion, to administer any medication that they deem to be required for the subject’s health and 
safety. 
There is no specific treatment requirement related to treating hypotension that may be observed in 
subjects with stroke who are also receiving NA-1. Treatment of emergent 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 subjects 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. 
All subjects will be monitored closely for these and other potential complications throughout the 
clinical trial.  All subjects will receive standard medical care as per local practice.      If hypotension 


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as defined above occurs, the hypotension and its treatment are to be recorded as an AE in the e-
CRF. 
10.2.3 Increases in Histamine 
NA-1 has undergone preclinical testing in rats, dogs, rabbits, and non-human primates.  When 
administered in these animals at doses higher than the one proposed in the current clinical trial, 
NA-1 has produced apparent anaphylactoid events characterized by histamine release in rats and 
dogs. The observed signs and symptoms were compatible with the physiological effects of 
histamine; specifically, transient hypotension and hives. This raises the possibility that 
anaphylactoid reactions to NA-1 could occur in humans. Patient susceptibility to drug-induced 
anaphylactoid events is highly variable. Therefore, potentially severe anaphylactoid reactions to 
the study drug may be encountered. Anaphylactoid reactions, including histamine-related reactions 
such as urticaria, bronchoconstriction, or hypotension, should be monitored.  In the event that an 
anaphylactoid reaction requiring treatment occurs, treatment should follow the same algorithms as 
would be followed if a spontaneous anaphylactoid reaction occurred in the community.  
•
Follow emergency medicine ABCs and establish airway first.
•
Treat hypotension with crystalloid, colloid and/or vasopressors as needed (see Section
10.2.2).
•
Consider treatment with antihistamine agents (diphenhydramine 50 mg IV, ranitidine 50
mg IV) and corticosteroids if the reaction is severe.
•
Consider using subcutaneous or intravenous epinephrine.
•
If bronchospasm or laryngospasm are important symptoms, consider treatment with
inhaled racemic epinephrine.
10.2.4 Hyperglycemia 
In the Phase 1 study, 9% of all subjects receiving any dose of NA-1 (0.02-3.75 mg/kg) had 
increases in blood glucose, as measured in their laboratory sample. However, in the Phase 2 study, 
there were no noteworthy differences between the NA-1 and placebo groups in blood glucose 
across time and at no time point did greater than two subjects have a clinically significant abnormal 
blood glucose result in either treatment group.   
In this study, serum electrolytes and blood glucose will be drawn as per the schedule of 
assessments as well as part of the standard-of-care. If hyperglycemia is noted, the physician will 
treat the subject on a case-by-case basis. As there is no known relationship between NA-1 
administration and hyperglycemia (based on rat, dog, and human studies), there is no unique 
protocol for blood sugar management following NA-1 administration. 
10.3 Identification of Adverse Events by the Investigator 
AE monitoring and reporting will be followed-up until Day 30. SAEs will be followed through the 
final study exit visit (Day 90 Visit or death or end of study whichever is sooner) or until the subject 
is deemed “lost to follow-up”. 


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AE identification while the subject is admitted to the acute stroke hospital will be collected via 
acute stroke hospital patient records and verbal histories from the subject or LAR.   For follow 
up visits after discharge from the acute stroke hospital the subject (or LAR if the subject 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. 
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. 
A consistent methodology of eliciting AEs at all subject evaluation timepoints will be used.  
Non-directive questions include: 
•
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?
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. 
10.4 Reporting of Adverse Events 
AEs should be reported as they occur on the e-CRF.  Documentation must be supported by an 
entry in the subject’s file.  Each event should be described in detail along with start and stop dates, 
severity, relationship to investigational product as judged by the Investigator, action taken and 
outcome. 
10.5 Reporting of Serious Adverse Events 
In order to comply with current regulations on SAE reporting to health authorities, the Investigator 
must document all SAEs regardless of causal relationship and notify the Sponsor. The Investigator 
will give access and provide the Sponsor with all necessary information to allow the Sponsor to 
conduct a detailed analysis of the safety of the investigational product. It is the responsibility of 
the Investigator to request all necessary documentation (e.g., medical records, discharge summary, 
autopsy) in order to provide comprehensive safety information. All relevant information must then 
be transcribed into the e-SAE Form. 
10.5.1 Reporting by the Investigator 
All SAEs must be reported to the Sponsor within 24 hours of the local Investigator’s first 
awareness of its occurrence.  SAEs will be reviewed by the trial medical monitor. 
The investigator will report the SAEs using the eSAE form in the eCRF, which will send an 
immediate alert to the Sponsor.  If the eCRF system is not available, a paper SAE form should be 
directed within 24 hours to: 


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Pharmacovigilence, NoNO Inc. 
redacted
10.5.2 Reporting SAEs to the Health Authorities and Ethics Committees 
The Sponsor will inform the relevant health authorities of any reportable SAEs according to the 
local regulatory requirements. Reporting to the health authorities will be according to the 
Sponsor’s standard operating procedures. 
SAEs that are assessed by the Sponsor to be unexpected and related to study drug (expedited 
reporting SAEs) will be reported to the regulatory agencies (i.e., Health Canada, European 
Medicines Agency and FDA) as per country requirements.  All other SAEs will be reported to 
regulatory agencies based upon local reporting requirements. 
The Sponsor’s medical monitor or designee 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.  
10.6 Additional Safety Assessments 
All pre and post dose vital signs, biochemistry, hematology laboratory tests and 
electrocardiograms must be reviewed by the investigator or qualified designee.  Clinically 
significant results post dose will be recorded as an adverse event. 
10.6.1 Vital Signs 
Vital signs (BP, HR) will be taken in the supine position at Baseline (pre-dose), at the completion 
of drug infusion, 24 Hours, 48 Hours and Day 5/discharge.  Temperature will be taken at baseline 
per standard of care and reported on the CRF if available.  The Investigator will review the pre and 
post drug infusion vital signs.  
If estimated weight was collected at randomization, the subject’s actual weight will be measured 
in hospital using standard hospital scales (i.e., stand up or in-bed scales if the subject is not 
ambulatory), as soon as possible, but within five days.  If actual weight cannot be measured for 
any reason (due to, for example severe illness or unavailability of in-bed scales at the site), weight 
will be determined by first asking the subject, second asking a family member or third by 
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10.6.2 Biochemistry and Hematology 
Blood work will be taken at baseline and at 24 hours including:  CBC (hemoglobin, platelets and 
hematocrit), electrolytes (sodium, potassium, chloride), INR, aPTT, serum creatinine and serum 
glucose.   This is  described in Sections 8.6. , 8.11 and the Schedule of Assessments. 
If the subject is female and is of childbearing potential, a pregnancy test (urine or serum point-
of-care pregnancy test) must be completed.  Clinically significant laboratory findings from the 
24-hour sample (post dose) will be recorded on the e-CRF as AEs.
10.7 12-Lead Electrocardiogram Monitoring. 
A 12-lead ECG will be performed at Baseline or, if the treating physician deems that an ECG 
will impede the subject’s access to care, within 6 hours of randomization, and at approximately 
24 Hours. Clinically significant findings on the 24-hour ECG will be recorded on the e-CRF as 
AEs. 
10.8 Concomitant Medications 
Concomitant medications (Conmeds) will be collected from the time of randomization to the Day 
30 Visit/contact. Conmed identification maybe collected via acute stroke hospital patient records 
or verbal histories from the subject or LAR.  Conmeds received while the subject is admitted to 
the acute stroke hospital will be identified from both hospital records and verbal histories.  
After discharge from the acute stroke hospital and for the Day 30 visit, the subject (or LAR if the 
subject is not able to respond to the questions) will be asked about medications taken since the last 
contact. Conmeds that were ongoing at the last contact will be updated with a stop date or 
confirmed as ongoing at Day 30.    
10.9 Safety and Data Review 
In addition to the site investigator’s review and IDMC reviews, on a regular basis the sponsor and 
external medical monitor will conduct a blinded safety and data review of the subject data collected 
to date in accordance with the Sponsor’s Safety Management Plan. 
10.10 Follow-up and Reporting of Pregnancies 
Pregnancy is an exclusion criterion for enrolment in this study, but a subject could potentially 
become pregnant during her participation. All pregnancy cases should be reported if they occurred 
during the study. To report the pregnancy case, the Investigator must fill out a Pregnancy Reporting 
Form and inform the Sponsor within one month of identifying a pregnancy case. Study staff must 
then maintain contact with the subject to obtain information about the outcome—i.e., details about 
the delivery and the newborn, or about pregnancy termination—and must update the Pregnancy 
Reporting Form.  This information should be provided to the Sponsor within one month of 
delivery. 
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, 


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and the information should be provided to the Sponsor regardless of when the SAE occurs (e.g., 
even after the end of the trial). 


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11 STATISTICS 
11.1 Sample Size Considerations 
Assuming a 52% overall responder rate for the placebo group, there will be an approximately  80% 
power to detect an 8.7% absolute effect difference between response rate (proportion of 
responders, with Day 90 mRS in the range 0 to 2) with NA-1 and placebo, at alpha level 0.05, 2-
sided with a planned sample size of 1076 evaluable subjects, randomized 1:1, per group, 
accounting for a single interim analysis when 600 subject have reached their primary endpoint 
assessments, with O’Brien-Fleming alpha-spending function (EaST® V6.3) stopping boundary for 
overwhelming efficacy and a non-binding 1% conditional power futility stopping boundary. The 
sample size will be inflated approximately 4% to N= 560 per group to account for loss-to-follow-
up and drop-outs.  
11.2 Analysis Populations 
11.2.1 ITT Population 
The primary efficacy analysis will be conducted in the ITT population, defined as all subjects 
randomized into the trial with grouping by randomized treatment, regardless of treatment actually 
received.  Deceased subject will be included in the ITT population with a mRS score of 6. An ITT 
analysis will also be conducted for the secondary endpoints, with subject grouped according to the 
randomized (intended) treatment. 
11.2.2 Per Protocol 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. This population will be 
determined via blinded review of protocol deviations at the end of the trial before database lock 
and unblinding. 
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 hence for the trial. 
This will include review of baseline NCCT and CTA.  Subjects who do not meet the imaging 
criteria outlined in the trial inclusion/exclusion criteria, will not be included in the Per Protocol 
(PP) population. 
11.3 Analysis of Primary Efficacy Outcome 
The primary efficacy outcome for the pivotal assessment of efficacy for regulatory purposes is the 
overall proportion subjects experiencing a favorable functional outcome 90-days post-
randomization, defined as 0 to 2 on the mRS. These subjects are defined as responders.  Subjects 
missing the day 90 primary assessment for any reason will be considered non-responders for the 
primary analysis (see Section 11.8). The primary hypothesis to be tested is that administration of 
NA-1 will result in an increase in the proportion of subjects with independent functioning on the 
mRS (as defined by a score of 0-2) at Day 90.  The primary analysis will be a Wald test for 
treatment group difference in the primary outcome from a logistic regression adjusted for the 2 
stratification variables (alteplase use, first declared thrombectomy device) and the 6 covariates 
used in the minimization:  Age, sex, baseline NIHSS score, baseline ASPECTS score, occlusion 


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location  and site. This will be conducted on the ITT population at the 2-sided 5% significance 
level overall (for the trial), adjusted for the interim analysis per the O’Brien-Fleming boundary 
spending function. 
Three supportive 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 and (3) The primary analysis will be 
repeated on the PP population using actual first endovascular approach (instead of declared 
approach). Details of these are provided in the Statistical Analysis Plan. 
11.4 Key Secondary Outcome Analysis 
The study will also test the secondary hypothesis that among randomized subject, those who are 
treated with NA-1 will show shift in the distribution of scores on the mRS scale at 90 days, 
assuming that categories 5 and 6 (bedbound with severe disability, and death) are collapsed.  This 
secondary outcome will use an adjusted proportional odds model to derive the common odds of 
improvement (“shift”) along the mRS scale.  Adjustment will include all of the variables in the 
stratification and minimization algorithm (age, sex, baseline NIHSS score, baseline ASPECTS 
score, occlusion location, intravenous alteplase treatment, declared first endovascular approach 
used and site). The proportional odds assumption will be tested. 
The choice of the shift analysis is based upon empirical evidence that the mRS scale, when 
categories 5 and 6 are combined, is a true interval scale meaning that any one step increment in 
the scale is the same; thus, it is unlikely that the proportional odds assumption will be violated and 
clinical step changes across the scale are meaningful.42  The proportional odds approach to analysis 
of the mRS scale was applied in the ESCAPE trial.3,43  It allows us to include elderly subject (who 
have a poorer prognosis irrespective of treatment) because a shift from severe to moderate 
disability will still be recognized as an important outcome. 


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Figure 2: Projected outcome by mRS category based data from the ESCAPE trial and 
estimation of NA-1 effect based on the minimal clinically important difference. 
Predicted outcomes by mRS category in the control group are from the ESCAPE trial.3  This 
shows an average 2-3% improvement in outcomes within each mRS category. 
If the distribution of subject follows that shown in Figure 2 (i.e. optimally shows a shift across the 
full scale with common OR 1.32), simulation (n=5000 iterations) demonstrates that the power will 
be 97.2% to show a common OR of 1.32 with 1076 evaluable subject.  
All tests will be conducted with two-sided level of significance alpha = 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, key secondary 
analysis second, etc.), after the first test which fails.: All tests after the first failed test are 
considered exploratory. For the purpose of clarity, since the key secondary analysis of the ordinal 
mRS scores will employ a proportional odds model (POM), if the proportional odds assumption 
fails, this key secondary analysis will not be performed, and the remaining secondary tests will 
still be considered to be protected. 
The fixed sequential order for testing in the ITT trial population is: 
1) Primary efficacy outcome
2) Key secondary outcome analysis (shift analysis using proportional odds model);
3) Secondary efficacy endpoints, as specified in the order presented below in Section 11.5.
11.5 Analysis of Secondary Efficacy Outcomes 
The key secondary outcomes will be tested in the following order: 
1. Shift analysis of 90 day mRS under proportional odds model across the mRS scale, as
described in Section 11.4 above.
2. The NIHSS 0-2 vs. 3 or greater at 90 days.
3. The BI at 95-100 vs. 0-90.
4. The mortality rate at 90 days.
5. The proportion of subjects with mRS score of 0-1 at Day 90.
15
17
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10
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11.5.1 Modified Rankin Scale – Shift Analysis 
The mRS shift analysis will be conducted as described in Section 11.4 above. 
11.5.2 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 subject achieving a good neurological outcome at 
Day 90 or the last rating in NA-1 versus placebo control subjects will be compared using the same 
logistic regression model as in the primary efficacy. 
11.5.3 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 subject with 
independent functioning with activities of daily living at Day 90 in NA-1 versus placebo control 
subjects will be compared using the same logistic regression model as in the primary efficacy. 
11.5.4 Mortality Rate 
Mortality rates, as defined as the number of deaths observed divided by the number of subject 
observed over the 90 day study period between NA-1 and placebo control subjects, will be 
analyzed by the same logistic regression model as in the primary efficacy. 
11.5.5 Modified Rankin Scale – 0-1 Dichotomy Analysis 
The mRS scores will also be dichotomized into 0-1 (indicating freedom from disability) and > 1 
(indicating otherwise). The proportion of subject with freedom from dependence/disability at Day 
90 in NA-1 versus placebo control subjects will be compared using the same logistic regression 
model as in the primary efficacy. 
11.6 Analysis of Tertiary Efficacy Outcomes 
11.6.1 EQ-5D-5L 
For the EQ-5D-5L, the difference between NA-1 and placebo control subjects in the distribution 
of the index and VAS scores on these scales at Day 90 will be presented descriptively. 
11.6.2 Volume of Stroke 
The total volume of new a) DWI and b) FLAIR lesions in NA-1 versus placebo control subjects 
will be calculated using a linear regression using a cubic root transformation.  Total volume will 
be assessed using a linear regression using a cubic root transformation if needed. An ANCOVA 
will be fit and summarized. 
Specific covariates are listed in Section 11.7.  
11.6.3 Cognitive outcomes 
These will be explored using the BNT15, SNAP and the MoCA. 


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11.6.4 mRS at 30 Days 
The overall proportion subjects experiencing a favorable functional outcome 30-days post-
randomization, defined as 0 to 2 on the mRS.  
The tertiary and all other analyses will be considered exploratory.  Details of the methods of 
analysis will be finalized in the SAP prior to the first IDMC meeting. 
11.6.5 Pharmacokinetics  
Descriptive statistics will be calculated for plasma concentrations and for all PK parameters 
(NA-1). 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. 
11.7 Adjustment for Covariates and Subgroup Analyses 
In addition to the primary and secondary analyses adjusting for age, sex, baseline NIHSS score, 
baseline ASPECTS score, occlusion location, intravenous alteplase use, declared first 
endovascular device and site, exploratory analyses will be conducted to determine the potential 
roles of common baseline characteristics and assess potential heterogeneity of treatment effect 
across subgroups.  Specific subgroups of interest include the very elderly (age > 80 years), men 
vs. women, subject with different baseline stroke severity (on NIHSS and measured radiologically 
on ASPECTS), subject treated with intravenous alteplase (yes/no), declared first endovascular 
approach, baseline occlusion location (MCA vs. ICA), and subject with long/short time from onset 
to treatment.  Full details will be specified in detail in the SAP. 
11.8 Handling of Missing, Unused and Spurious 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.  
This was kept to a minimum of 1.3% in the ESCAPE trial3. Deceased subject will score 6 on the 
mRS and be counted as non-responders. For the primary analysis for regulatory submission, we 
will assume that subject missing the primary endpoint data will be considered to be non-
responders. 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 
subject randomized are missing the primary endpoint. 
11.9 Analyses of Safety 
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. 
11.9.1 SAEs 
SAEs over the 90-day study period will be summarized by presenting, for each treatment group, 
the number and percentage of subjects having at least one SAE, having an SAE in each body 


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system and preferred term, by severity and relatedness to study medication. The frequencies and 
incidences of SAEs 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 SAEs and 
discontinuations due to SAEs occurring in subjects in the NA-1 and placebo control groups will 
be summarized within treatment group. 
11.9.2 Mortality 
Event rate (%) for mortality over the 90-day study period between NA-1 and placebo control 
subjects will be compared by logistic regression. The logistic regression model will include factors 
for treatment group.  All deaths will be provided in a listing. 
11.9.3 AEs 
Additional analyses will consider the frequency of AEs and discontinuations due to AEs. AEs will 
be summarized by presenting, for each treatment group, the number and percentage of subjects 
having any AE, having an AE in each body system and preferred term. Severity and relatedness to 
study medication will be recorded according to Table 10-1. 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). 
11.9.4 Vital Signs 
Absolute values and changes for vital signs from pre-dose to Day 5 or discharge will be 
documented. The maximum deviation of BP from Baseline between drug and placebo control 
groups (systolic and diastolic) to 24 Hours will be analyzed using ANCOVA, including factors for 
treatment group. 
11.9.5 
Laboratory and 12-Lead ECG Results 
Absolute values for laboratory results and generalized 12-lead ECG results (i.e., normal, sinus 
bradycardia, etc.) will be documented descriptively.    
11.9.6 Prior and Concomitant Medications 
Prior and concomitant medications will be listed per patient, with the listings separated within 
treatment group. 
11.10  Independent Data Monitoring Committee 
An IDMC will perform periodic safety reviews of the clinical data. The reviews will occur when 
100, 300 and 600 subjects have reached their Day 90 final study visit.  
An efficacy interim analysis after approximately 600 subjects complete the Day 90 follow-up will 
be conducted using the alpha spending function method1 with O’Brien and Fleming2 type stopping 
boundary for efficacy and a  non-binding conditional power boundary for futility.   The trial may 
be stopped for overwhelming efficacy or for futility at the interim analysis if the test statistic 
crosses the O-F or conditional power boundary.  The IDMC charter will describe, among other 


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things, the approach to handling overwhelming efficacy, futility, and potential imbalance in key 
prognostic variables.  
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 subject 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.    
 


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12 DIRECT ACCESS TO SOURCE DATA/DOCUMENTS 
The sponsor or delegate will be permitted to visit the study facilities at any reasonable time in 
order to maintain current, detailed knowledge of the study through review of the records, source 
documents, observation, and discussion of the conduct and progress of the study.  In addition, the 
sponsor will maintain regular telephone and written communication with all investigators through 
the coordinating centre. The sponsor (or delegate) will be given complete access to all components 
of the study facility that pertain to the conduct of this study, and may be present to observe any 
aspect of the conduct of the study by medical and paramedical staff, including but not limited to 
drug preparations, dosing, sample collections, and clinical observations.  E-CRFs will be 
monitored with sufficient frequency to assess the following:  Subject randomization, compliance 
with protocol procedures, the completeness and accuracy of data entered into the e-CRFs, 
verification of e-CRF data against original source documents, and occurrence of AEs.  Adequate 
time and all documents for these monitoring visits must be made available by the investigators.  
The investigators will permit trial-related monitoring, audits, REB/IRB review, and regulatory 
inspections, providing direct access to source data/documents.  


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13 QUALITY CONTROL AND QUALITY ASSURANCE 
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 subjects.  In 
addition, 100% of subjects enrolled are monitored for the presence of signed consent and Health 
Insurance Portability and Accountability Act (HIPAA) and Personal Information and Portable 
Electronic Documents Act (PIPEDA) documentation, where applicable.  
Monitoring of the investigational sites will be conducted by the sponsor or contracted to a qualified 
CRO.  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. At site visits, the monitor will, as 
required, assess the progress of the study; check that the study data chosen for verification are 
authentic, accurate, and complete; verify that the safety and rights of patients are being protected; 
compare original documents with data entered into the study database; and identify any issues and 
address their resolution. 
The investigator agrees to 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. 
Additional on-site monitoring verification includes: ongoing evaluation of the adequacy of site 
facilities and staff, site recruitment, subject randomization, the presence of regulatory documents, 
and specific review of documents and data.  The initial performance-monitoring visit to a site takes 
place after the initial subject(s) are enrolled and will continue according to enrolment for the 
duration of the trial. 
During the monitoring visit, any omissions and corrections to data submitted to the database will 
be noted and queries will be generated by the monitor and resolved by the site.  
The close-out monitoring visit by the monitor will take place at the completion of subject 
enrollment and protocol required follow-up visits at the performance site.  At that visit, the monitor 
will again review the presence of a regulatory file and verify documents for currency and 
completion as directed by the CRU.  Sites will be instructed in the record retention of all trial 
documents. Principal Investigators are directed to close the trial and issue a final report to the 
IRB/REB. Finally, any additional special considerations for the auditing of any additional safety 
issues are made during this final monitoring visit. 
Except for an emergency situation in which proper care for the protection, safety and well- being 
of the study subjects 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. 


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13.1 Audits 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. 
13.2  Protocol Amendments and Revisions 
Should amendments and/or revisions to the protocol be required, they will be originated and 
documented by the sponsor. All amendments and/or revisions will be made in compliance with 
sponsor SOPs. All amendments will be submitted to the REB/IRB for approval prior to 
implementation. 
It is the sponsor’s responsibility to submit all revisions and amendments to regulatory authorities 
when necessary. 


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14 ETHICS 
14.1  Research Ethics Board/Institutional Review Board 
This study will be conducted in substantial compliance with the principles and requirements of the 
ICH-GCP, Canadian Food and Drug Regulations, United States Code of Federal Regulations 
(CFR; including Title 21 Parts 50, 54, 56, and 312), the Declaration of Helsinki and the Canadian 
Tri-Council Policy Statement on Ethical Conduct for Research involving Humans (2), where 
applicable. 
This protocol and the consent forms will be submitted to each hospital’s REB/IRB. Before 
initiation of the study, a copy of the REB/IRBs’ approval letters will be provided to the sponsor 
and the membership list of the REB/IRB will be kept on file.  
This protocol and the informed consent document and any subsequent modifications will be 
reviewed and approved by the REB/IRB responsible for oversight of the study.  For subjects who 
cannot consent themselves, an LAR may sign the consent form.  The consent form describes the 
purpose of the study, the procedures to be followed, and the risks and benefits of participation.  A 
copy of the consent form must be given to the subject and/or the LAR; and this fact must be 
documented in the subject’s record.  SAEs will be reported to the REB/IRB according to their 
requirements.   


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15 DATA HANDLING AND RECORDKEEPING 
15.1 Data Handling 
The database used in the study will be a 21 CFR Part 11 compliant database. During the trial, 
clinical data reported in the eCRFs will be integrated into the clinical database under the 
responsibility of the Sponsor or their qualified representative. Quality control in the form of 
computerized logic and/or consistency checks will be systematically applied in order to detect 
errors or omissions.  
In addition, 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. 
After integration of all corrections in the complete set of data, the database will be released for 
statistical analysis. 
15.2 Investigator Files/Retention of Documents 
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) Subject 
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.   
Subject clinical source documents (usually defined by the project in advance to record 
efficacy/safety parameters independent of the CRFs) would include subject 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 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 25 years. After that period of time the documents may be destroyed, subject 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. 
15.3 Source Documents and Background Data 
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 e-CRFs are illegible 


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or 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 subject confidentiality is protected. 
15.4 Case Report Forms 
For each subject randomized, an electronic CRF must be completed and signed by the investigator. 
If a subject withdraws from the study, the reason must be noted on the CRF.  
All forms should be completed within five business days of subject visit.  
All corrections will be tracked in the eCRF audit trail. The Investigator should ensure the accuracy, 
completeness, legibility, and timeliness of the data reported to the sponsor in the CRFs and in all 
required reports. 
15.5 Confidentiality 
All imaging, evaluation forms, reports, and other records that leave the site are identified only by 
the site and subject number to maintain subject confidentiality.  All records are kept in a locked 
file cabinet. Clinical information is not released without written permission of the subject, except 
as necessary for monitoring by REB/IRB, Health Canada, the sponsor, or the sponsor’s designee. 
All study investigators at the clinical sites must ensure that the confidentiality of personal identity 
and all personal medical information of study subjects are maintained at all times.  Federal 
legislation in Canada (PIPEDA), and provincial legislation [e.g. Health Information Act (HIA) in 
AB] where applicable, must be followed.  Additionally, any U.S. clinical sites must follow privacy 
obligations to study subjects under HIPAA.   European or Asian/Australasian sites must conform 
to local privacy and confidentiality law and custom.  On the CRFs and other study documents or 
image materials submitted to the CRU, the subjects are identified only by study identification 
codes. 
Personal medical information may be reviewed for the purpose of verifying data recorded in the 
CRF 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. 
 
 


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16 PUBLICATION AND PRESENTATION POLICY 
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  
17 ANCILLARY STUDIES POLICY 
Ancillary or sub-studies may be considered by the trial executive committee.  Important 
principles that guide the addition of ancillary studies are: 
1) No subject shall be enrolled in a concurrent investigational drug/device trial during the
study period
2) Concurrent enrollment of an ESCAPE-NA1 study subject in a site specific observational
cohort study is allowable, where the following conditions are met:
a.
The executive committee is notified
b. The concurrent study does not interfere with any study follow-up procedures or
potentially confound the outcome of the ESCAPE-NA1 trial
c.
The site principal/qualified investigator of the concurrent study explicitly
acknowledges that the treatment given in the ESCAPE-NA1 trial may confound
the outcome of the site-specific concurrent study
d. The subject may not be included in any publication or report until the ESCAPE-
NA1 study has been concluded
3) Ancillary or sub-studies shall be vetted and approved by the trial executive committee.


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18 DATA-SHARING PLAN 
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 Executive Committee will make the trial results available as free-access using PubMed and 
on Clinical Trials.gov (www.clinicaltrials.gov). 


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19 FINANCIAL CONSIDERATIONS 
Routine care is expected to be paid for by the existing standard medical insurance system.  This 
will include but is not limited to: 
•
Admission to hospital
•
Baseline laboratory testing, pregnancy test, ECG, baseline NCCT and CTA, baseline
CTP
•
Endovascular procedure and angiography
•
Follow-up limited-sequence MR brain imaging at 24 Hours
•
Follow up ECG at 24 Hours
•
Follow-up laboratory testing (other than the mandated tests at 24 hours)
•
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, CRF 
completion, adverse event reporting, concomitant medication reporting, submission of imaging 
to the core lab.  The study fees are inclusive of any local institutional overhead/indirect costs. 


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20 Appendix 1 – Additional Guidance on Imaging Selection and Endovascular Treatment 
Notes on Eligibility for Endovascular Therapy 
Eligibility for endovascular treatment has been defined by the recent randomized clinical trials. 
Guidance on selection of subject using imaging is as follows: 
Exclude subject with evidence of a large core of infarction (ASPECTS 0-4), evidence of very poor 
intracranial collaterals on CTA: 
•
A large core can be defined as a baseline NCCT reveals a moderate/large core defined as
extensive early ischemic changes of ASPECTS 0-4 in the territory of symptomatic
intracranial occlusion.
•
Poor collaterals can be defined on a multiphase or dynamic CTA: no or minimal collaterals
(ie. equivalent to a Tan score 0 or 1).  Poor collaterals can be similarly defined on single
phase CTA but with reduced specificity compared to CTA.  Multiphase or dynamic CTA
is required for the study.
We advise using the ESCAPE3 imaging criteria for selection of subject into the trial. 
Angiographic Process Measures 
Short imaging time: 
The total imaging time starts from the time the subject reaches the door of imaging suite to when 
the subject is out of there and ready to move to next step. It includes putting subject on table, 
setting intravenous line, connecting to pump, etc. In the case of MR it would include the time taken 
to exclude presence of pacemaker etc.   It includes post-processing time.  Imaging time should not 
exceed 15 minutes. 
Excellent overall organization to reduce CT-to-groin puncture time: 
There are multiple steps to get from imaging to the groin puncture and these may include: 
•
Image interpretation
•
Blood draw
•
ECG
•
Anesthesia involvement for conscious sedation
•
Prepping the angiography suite
•
Availability of nurse and technician
•
Availability of respiratory technician and anesthetist if appropriate
•
Ability to move the subject from the CT suite rapidly to the interventional suite
Groin puncture-to-recanalization time: 
From the time the subject is on angiography suite table: 
•
Pre-plan your procedure, catheters required by reviewing the CTA of the arch
•
Puncture the groin while the subject is getting draped.  Do not wait.


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•
Have a stroke kit ready.
•
Have a pre-decided division of labour: who is going to do what?
•
Simple things like shaving the groin: is it needed?
•
Foley catheter.  Draining the bladder improves subject comfort and help reduce BP
•
Assess need for anesthesia; overall general anesthesia should be avoided.  Involvement of
an anesthetist for conscious sedation is ideal.
•
Training on use of other drugs to hold subject still: consult with local anesthetist.
•
8F sheath.
•
Go straight to vessel of interest.
•
Choice of catheter dependent on CTA.
•
Whether common carotid artery run needed on not dependent on CTA.
•
Try to use standardized microcatheter and wire.
•
Plan an entire kit of stuff that is needed included things like a 60 cc syringe.
TICI2c or 3 flow: 
Aim for complete recanalization [Thrombolysis in Myocardial Infarction (TIMI) 3] and 
reperfusion (TICI 3).  A few small distal emboli are an acceptable outcome and are generally 
tolerated well by collateral flow. 
Control BP: 
While the artery remains occluded, systolic blood pressure (SBP) 150 or greater is probably useful 
in promoting and keeping collateral flow adequate.  Indirect evidence supports this assertion.  Once 
reperfusion has been achieved, BP often falls naturally.  Controlling BP once reperfusion has been 
achieved aiming for a normal BP for that individual is sensible.  Labetalol or an intravenous β-
blocker such as metoprolol in low doses is preferred. 
Keep complication rate low: 
Be prepared to stop and back out.  Do not take unnecessary risks.  Remember that you do not 
necessarily need a “perfect” angiographic outcome to have a good clinical outcome. 
Medical Management: 
Designate one person to observe and manage the subject’s vital signs.  Follow the oxygen 
saturation (SaO2), pulse and BP.  Manage accordingly.  In an ideal circumstance, an anesthetist 
helps manage this aspect of care.  
In the absence of an anesthetist, the standard of care is that the attending neurologist or stroke 
fellow will have a lead apron on and be in the neuro-angiosuite managing the medical and 
neurological condition of the subject. 
BP management is described above.  There are no clear guidelines that are based upon level 1 
evidence. 
Conscious Sedation Management: 
We strongly recommend that all sites avoid general anesthesia.  The vast majority of endovascular 
stroke treatment can be completed under conscious sedation.  Several case series support the 


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concept that general anesthesia is associated with poorer outcomes.  A possible explanation is 
prolonged BP lowering resulting in more rapid progression to infarction. 
A simple conscious sedation paradigm for adult subject is as follows: 
•
2.5 mg midazolam IV
•
25-50 µg fentanyl IV
These drugs should be given together since this avoids the occasional paradoxical agitation seen 
with intravenous benzodiazepines alone.  They can be given q10-15min.  Follow the RR and SaO2 
to avoid trouble with respiratory suppression.  Managing conscious sedation can be done by the 
neurologist or stroke fellow in the room.   
It is often additionally helpful to pre-treat subject with anti-nausea agents: 
•
25-50 mg dimenhydrinate (gravol) IV [available in Canada, not the US]
This drug is very mildly sedating and may help avoid an episode of aspiration. 
The only subject who typically will require intubation include those with paradoxical agitation 
associated with a Wernicke’s aphasia, or those who develop respiratory compromise due to 
aspiration or other event arising after randomization. 
Carotid artery stenting: 
It is recommended as a guideline that carotid artery stenting is should not be done as part of the 
treatment in the study.  Tandem occlusion of the extracranial carotid at the bifurcation associated 
with an M1-MCA occlusion is common.  Patients with tandem occlusions are eligible for 
enrolment.  The target lesion initially is the M1-MCA occlusion.  Advance a catheter past the ICA 
lesion and deal with the M1-MCA first.  Very often, in this process, the proximal ICA is open at 
the end of treating the M1-MCA because of the mechanical manipulation of the occlusive lesion 
at the carotid.  What was initially a 99% stenosis is reduced to 60 or 70%. 
At this point stop.  Treat the subject with ASA per rectum (since they cannot swallow) and bring 
the subject back the following day to decide on whether subsequent procedures are necessary.  It 
is simply not necessarily true that forward flow in the carotid is required to keep the M1-MCA 
open. 
The major potential difficulty with leaving a carotid stent in place is the need for antiplatelet 
therapy, which will increase the chance of major symptomatic bleeding. 
If, despite the above, the treating physician deems that a stent is required – either intracranially or 
at the carotid bifurcation because this action is in the patients’ best interest, we recommend using 
ASA and clopidogrel rather intravenous abciximab or eptifibatide.  Give ASA per rectum and as 
soon as possible give 600 mg clopidogrel per NG. 


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Use of IA medications: 
Use of intra-arterial medication such as alteplase, abciximab, epitifibatide, tirofiban is not advised 
although nothing in this protocol forbids the use of any treatment that the treating physician deems 
to be in the subject’s best interest. Any such medications will be noted in the CRF. Note that 
alteplase is not indicated for direct IA catheter delivery.   
Number of Devices / GP2b3a Inhibitors / When to stop: 
Some lesions are too difficult to treat and adequate recanalization may not be achieved.   The more 
devices that are used and the most antithrombotic agents that are used, the greater the risk of major 
AEs.  Use of intravenous GP2b3a inhibitors in the setting of AIS, is associated with a very high 
risk (up to 40%) of hemorrhage.  Please do not use them.  Please make every effort to achieve 
recanalization within 90 minutes of imaging.  If this is clearly not going to be achievable, the 
interventionalist and team must make a judgment as to whether to continue.  Spending more than 
90 minutes working on an intracranial lesion is a recipe for major AEs. 
Chasing distal M2, M3 or A2, A3 occlusions: 
Once the arterial occlusive lesion is open, there will remain visible distal occlusion approximately 
10-20% of the time.  Do not chase these.  Do not give regional alteplase infusion.  A perfect
angiographic outcome is not necessary for a good clinical outcome and there is a greater risk of
doing harm.


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21 Appendix 2: Derivation of ASPECTS on NCCT and Collaterals Scoring on CTA 
Minimal Acceptable Quality for CT scan 
There is potential for variation across sites as to the choice of imaging modalities that treating 
physicians use for deciding appropriate subject for intervention.  Overall, CT is the mainstay for 
this trial and all patients must be selected on the basis of CT and multiphase or dynamic CTA, to 
standardize imaging patient selection criteria. 
• NCCT 
• CTA from arch to head 
NCCT quality 
• Minimum power: 120-140 kV, 170-200 mA  
• Two second scanning time 
• 5 mm section thickness 
• Appropriate algorithm reducing bone artefacts and high SNR for gray-white 
differentiation 
• Contiguous axial sections from skull base to vertex parallel to the inferior orbitomeatal 
line (IOML) 
• A good quality stroke protocol scan is defined by the following two criteria on the 
unaffected side:  Lateral margin of the lentiform nucleus well discriminated in the 
absence of previous infarction. 
• Insular ribbon is well defined in the absence of previous infarction. 
• CTA should use minimum contrast media –75cc is the recommended amount  
• Helical acquisition 
• Reformats should include:  thin (3mm) axial, sagittal, coronal maximum intensity 
projection (MIPS), thick (25 mm) axial and sagittal MIPS  
NCCT  
NCCT shall be scored using ASPECTS, a 10-point score derived by examining each of 10 regions 
on the middle cerebral artery territory.  Ischemic change present is scored as 0; ischemic change 
absent is score as 1.  Adding up the score gives a maximum of 10 (favourable scan) and minimum 
of 0 (unfavourable scan). 
The score is highly reliable when trichotomized into 0-4 (severe ischemic change, large core), 5-7 
(moderate ischemic change) and 8-10 (minimal ischemic change, small core).  ASPECTS may be 
less reliable early in stroke (i.e. within 90 minutes of onset); however, at later time windows it 
should be easy to recognize large areas of irreversible damage.  Having a good quality scan and 
optimization of scanner is key to successful interpretation.  Further information is available at:  
www.aspectsinstroke.com. 
CTA 
The importance of contrast bolus timing should be emphasized.  Using single-phase CTA, it is 
important to have a sufficiently venous weighted study to be able to visualize the collateral 


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circulation adequately.   The CTA must include the aortic arch to allow the interventionalist a view 
for planning. 
Multi-phase (3 or 4 phase) CTA will be used to show the evolution of the blood flow.  This 
technique is particularly useful in demonstrating regional blood flow hang-up and implicated distal 
circulation occlusions.  The timing of mCTA imaging depends upon the individual CT scanner 
and table speed. By vendor, there is approximately 5-8 seconds between phases.  See: 
www.aspectsinstroke.com. 
Scoring of Collateral Status 
The CTA will be assessed for collateral status using a standardized technique similar to the 
ESCAPE trial. Collaterals are measured on multi-phase CTA by comparing backfilling pial vessels 
beyond the blocked artery to similar vessels in the opposite, unaffected hemisphere (Figure A1).  
This is done for all phases of the CTA, which depending upon the machine type will vary from 5-
8 seconds apart in time.  Vascular enhancement distal to occlusion is scored in anterior and 
posterior MCA territories as visualized on all CTA slices, and typically reviewed on axial thick 
maximal intensity projections (MIPs). By examining all 3 phases, the degree of filling of the pial 
vessels in time can be assessed.  Delayed filling and delayed washout ipsilateral to the occluded 
artery is expected.  The aim in the ESCAPE-NA1 trial is to exclude patients with absent or near 
absent pial collateral filling on all phases of the CTA.  Phase 1 (early) absence or minimal filling 
with later (phase 2 and 3) robust filling represents strong collaterals and an ideal treatment 
candidate. 
The following scoring system provides a guide.  Patients with a score of 0 or 1 will be excluded 
for this study. 
Category 
Score 
Description 
Good 
5 
Compared to asymptomatic contralateral hemisphere, there is no delay 
and normal or increased prominence of peripheral vessels/ normal extent 
within the occluded arteries territory within the symptomatic hemisphere. 
4 
Compared to asymptomatic contralateral hemisphere there is a delay of 
one phase in filling in of peripheral vessels but prominence and extent is 
the same.  
Intermediate 3 
Compared to asymptomatic contralateral hemisphere there is a delay of 
two phases in filling in of peripheral vessels but prominence and extent is 
the same or there is a one phase delay and decreased prominence (thinner 
vessels) / reduced number of vessels in some part of the territory 
occluded.  
2 
Compared to asymptomatic contralateral hemisphere there is a delay of 
two phases in filling in of peripheral vessels and decreased prominence 
and extent or a one-phase delay and some regions with no vessels in 
some part of the territory occluded.  
Poor 
1 
Compared to asymptomatic contralateral hemisphere there are just a few 
vessels visible in any phase within the occluded vascular territory.  
0 
Compared to asymptomatic contralateral hemisphere there are no vessels 
visible in any phase within the occluded vascular territory.  


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*On a single phase, multiphase or dynamic CTA:  no or minimal collaterals in a region greater
than 50% of the MCA territory when compared to pial filling on the contralateral side can also
be considered as poor collaterals (Score = 1).
Figure A1. Upper panel shows a patient with a left M1 MCA occlusion (arrow) and good collaterals 
(backfilling arteries) on multi-phase CTA. Middle Panel shows a patient with a left M1 MCA occlusion 
(arrow) and intermediate collaterals. Lower panel shows a patient with a right M1 MCA occlusion 
(arrow) and poor collaterals (minimal backfilling arteries) on multi-phase CTA.  
A teaching slide set and module will be available for use within the trial. 


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22 Appendix 3 – Randomization Details. 
The initial randomization of the first 40 subject will be completed using a simple random number 
generator yielding an unblocked randomization with an equal probability for each treatment arm. 
Thereafter, randomization will be stratified by intravenous alteplase use and declared endovascular 
approach combined with a randomized minimization method from Zhao et al, called the minimal 
sufficient balance method23.  This approach will ensure that the subjects entered into the trial will 
be matched between control and active treatment arms on the key variables of age, sex, baseline 
NIHSS score, baseline ASPECTS score, occlusion location (MCA or ICA), and site. This method 
will ensure that during the trial and by the end of the trial, the subjects are well matched for 
important prognostic variables and therefore the chance that any treatment effect is confounded by 
a specific variable is severely attenuated, because the groups are balanced on known important 
prognostic variables. Minimization will also provide some assurance that adequate balance will be 
maintained even at the time of interim analysis. 
A randomization website, using user and site level secure access, will assign treatment in real time. 
Five key clinical variables (age, sex, baseline NIHSS score, baseline ASPECTS score, occlusion 
location (MCA or ICA)), and one site variable, defined by the user log in credentials, will be used 
in the minimization procedure.  Age will be calculated against the central server date and time, 
which will be synchronized weekly to the Denver atomic clock. In this method, balance will be 
checked on the six variables using a simple t-test for continuous variables and a χ2 test for binary
variables.  If the p-value for the test is <0.3, then imbalance is considered present and a vote is 
given to that variable to randomize to Group A or Group B to minimize imbalance.  If the 
summation of six votes favours, for example, Group A allocation, then a biased coin randomization 
probability of 0.65 is used and the probability of allocation to Group A becomes 0.65.  If the votes 
are equal, then the probability remains 0.5.  This methodology was successfully used in the 
ESCAPE trial3.  A permutation test for covariate balance was undertaken at the end of the trial and 
showed no evidence of biased treatment allocation.  This same approach will be repeated in the 
ESCAPE-NA1 trial to demonstrate that the minimization algorithm was effective.  Treatment 
assignment will always be fully concealed since it will be assigned in real-time based upon random 
number generation. 


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23 REFERENCES 
1. 
Lan KKG DD. Design and analysis of group sequential tests based on type-I error 
spending rate function. Biometrika 1987;74:149-54. 
2. 
O'Brien PC FT. A multiple testing procedure for clinical trials. Biometrics 
1979;35:549-56. 
3. 
Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid 
endovascular treatment of ischemic stroke. N Engl J Med 2015;372:1019-30. 
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Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke 
with perfusion-imaging selection. N Engl J Med 2015;372:1009-18. 
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Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-
PA vs. t-PA alone in stroke. N Engl J Med 2015;372:2285-95. 
6. 
Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom 
onset in ischemic stroke. N Engl J Med 2015;372:2296-306. 
7. 
Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial 
treatment for acute ischemic stroke. N Engl J Med 2015;372:11-20. 
8. 
Cook DJT, L.; Tymianski, M. Treatment of Stroke with a PSD95 inhibitor in the 
Gyrencephalic Primate Brain Nature 2012;483:213-7. 
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Sun HS, Doucette TA, Liu Y, et al. Effectiveness of PSD95 inhibitors in permanent and 
transient focal ischemia in the rat. Stroke 2008;39:2544-53. 
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Cook DJT, L.; Tymianski, M. A translational paradigm for the preclinical evaluation of 
the stroke neuroprotectant Tat-NR2B9c in gyrencephalic nonhuman primates. Science 
Translational Medicine 2012;4:1-8. 
11. 
Hill MD, Martin RH, Mikulis D, et al. Safety and efficacy of NA-1 in patients with 
iatrogenic stroke after endovascular aneurysm repair (ENACT): a phase 2, randomised, 
double-blind, placebo-controlled trial. Lancet Neurol 2012;11:942-50. 
12. 
Kornau HC, Schenker LT, Kennedy MB, Seeburg PH. Domain interaction between 
NMDA receptor subunits and the postsynaptic density protein PSD-95. Science 
1995;269:1737-40. 
13. 
Aarts M, Liu Y, Liu L, et al. Treatment of ischemic brain damage by perturbing NMDA 
receptor- PSD-95 protein interactions. Science 2002;298:846-50. 
14. 
Fisher M. The ischemic penumbra: identification, evolution and treatment concepts. 
CerebrovascDis 2004;17 Suppl 1:1-6. 
15. 
Bratane BT, Cui H, Cook DJ, Bouley J, Tymianski M, Fisher M. Neuroprotection by 
Freezing Ischemic Penumbra Evolution Without Cerebral Blood Flow Augmentation With a 
Postsynaptic Density-95 Protein Inhibitor. Stroke 2011;42:3265-70. 
16. 
Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after 
acute ischemic stroke. NEnglJMed 2008;359:1317-29. 
17. 
Hill MD, Martin RH, Mikulis D, et al. Safety and efficacy of NA-1 in patients with 
iatrogenic stroke after endovascular aneurysm repair (ENACT): a phase 2, randomised, 
double-blind, placebo-controlled trial. The Lancet Neurology 2012;11:942-50. 
18. 
Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after 
intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013;368:893-903. 
19. 
Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular 
treatment for ischemic stroke. N Engl J Med 2013;368:914-23. 


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20. 
Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute 
ischemic stroke. N Engl J Med 2013;368:904-13. 
21. 
Albers GW, Thijs VN, Wechsler L, et al. Magnetic resonance imaging profiles predict 
clinical response to early reperfusion: the diffusion and perfusion imaging evaluation for 
understanding stroke evolution (DEFUSE) study. Ann Neurol 2006;60:508-17. 
22. 
Puetz V, Dzialowski I, Hill MD, Demchuk AM. The Alberta Stroke Program Early CT 
Score in clinical practice: what have we learned? International journal of stroke : official 
journal of the International Stroke Society 2009;4:354-64. 
23. 
Zhao W, Hill MD, Palesch YY. Minimal Sufficient Balance – A new strategy to balance 
baseline covariates and preserve randomness of treatment allocation. Stat Meth Med Res 
2012;In press. 
24. 
Johnston SC, Leira EC, Hansen MD, Adams HP, Jr. Early recovery after cerebral 
ischemia risk of subsequent neurological deterioration. Ann Neurol 2003;54:439-44. 
25. 
Rothwell PM, Eliasziw M, Gutnikov SA, Warlow CP, Barnett HJ. Endarterectomy for 
symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet 
2004;363:915-24. 
26. 
Krol AL, Dzialowski I, Roy J, et al. Incidence of radiocontrast nephropathy in patients 
undergoing acute stroke computed tomography angiography. Stroke 2007;38:2364-6. 
27. 
Gonzales DA, Norsworthy KJ, Kern SJ, et al. A meta-analysis of N-acetylcysteine in 
contrast-induced nephrotoxicity: unsupervised clustering to resolve heterogeneity. BMC 
Med 2007;5:32. 
28. 
Klima T, Christ A, Marana I, et al. Sodium chloride vs. sodium bicarbonate for the 
prevention of contrast medium-induced nephropathy: a randomized controlled trial. Eur 
Heart J 2012. 
29. 
U.S. Department of Health and Human Services FaDA. Guidance for Sponsors, 
Clinical Investigators, and IRBs:  Data Retention When Subjects Withdraw from FDA-
Regulated Clinical Trials. In: Services USDoHaH, ed. Rockville, MD: Food and Drug 
Administration; 2008. 
30. 
Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin scale: 
implications for stroke clinical trials: a literature review and synthesis. Stroke 
2007;38:1091-6. 
31. 
Quinn TJ, Dawson J, Walters MR, Lees KR. Reliability of the modified Rankin Scale: a 
systematic review. Stroke; a journal of cerebral circulation 2009;40:3393-5. 
32. 
Kasner SE. Clinical interpretation and use of stroke scales. Lancet Neurol 
2006;5:603-12. 
33. 
Mahoney FI, Barthel DW. Functional Evaluation: The Barthel Index. Md State Med J 
1965;14:61-5. 
34. 
Quinn TJ, Langhorne P, Stott DJ. Barthel index for stroke trials: development, 
properties, and application. Stroke; a journal of cerebral circulation 2011;42:1146-51. 
35. 
Brooks R. EuroQol: The current state of play. Health Policy 1996;37:53-72. 
36. 
Herdman M, Gudex C, Lloyd A, et al. Development and preliminary testing of the new 
five-level version of EQ-5D (EQ-5D-5L). Quality of life research : an international journal of 
quality of life aspects of treatment, care and rehabilitation 2011;20:1727-36. 


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37. 
Kaplan E GH, Weintraub S. The Boston Naming Test. Philadelphia, PA: Lea and 
Febiger;1983. 
38. 
Leibovitch FS VB, Ebert PL, Beresford KL, Black SE. A short bedside battery for 
visuoconstructive hemispatial neglect:  Sunnybrook Neglect Assessment Procedure (SNAP). 
J Clin Exp Neuropsychol 2012;34:359-68. 
39. 
Cumming TB BJ, Linden T. The Montreal Cognitive Assessment:  Short Cognitive 
Evaluation in a Large Stroke Trial. Stroke 2011;42:2642-4. 
40. 
Godefroy O FA, Roussel M, Auribault C, Bugnicourt JM, Lamy C, Canaple S., 
Petitnicolas G. Is the Montreal Cognitive Assessment superior to the Mini-Mental State 
Examination to detect post-stroke cognitive impairment?  A study with neuropsychological 
evaluation. Stroke 2011;42:1712-6. 
41. 
Graves RE BS, Fogarty J, Blair R. Boston Naming Test Short Forms:  A Comparison of 
Previous Forms with New Item Response Theory Based Forms. Journal of Clinical and 
Experimental Neuropsychology 2004;26:891-902. 
42. 
Hong KS, Saver JL. Years of disability-adjusted life gained as a result of thrombolytic 
therapy for acute ischemic stroke. Stroke; a journal of cerebral circulation 2010;41:471-7. 
43. 
group ISTc, Sandercock P, Wardlaw JM, et al. The benefits and harms of intravenous 
thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic 
stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet 
2012;379:2352-63. 
 
 
 


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24 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 
Intravenous NA-1 in Subjects with Acute Ischemic Stroke Undergoing Endovascular 
Thrombectomy (ESCAPE-NA1 Trial), Version 9.0 dated 19 February  2019 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 

SAP_001.pdf: 
CONFIDENTIAL 
NoNO Inc. 
 
Protocol NA-1-007 
Statistical Analysis Plan 
NA-1 
 
 
Date: 09 May 2019; Version: 3.0 
 
 
 
 
STATISTICAL ANALYSIS PLAN 
 
NoNO, Inc. 
Toronto, Ontario 
 
Protocol NA-1-007 
 
A Multicenter, Randomized, Double-blinded, Placebo-controlled, Parallel Group,  
Single-dose Design to Determine the Efficacy and Safety of Intravenous NA-1 in  
Subjects with Acute Ischemic Stroke Undergoing Endovascular Thrombectomy 
(ESCAPE-NA1 Trial) 
 
 
 
 
09 May 2019 
 
 
Version 3.0 
 
 
 
 
 


CONFIDENTIAL 
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Protocol NA-1-007 
Statistical Analysis Plan 
NA-1 
Date: 09 May 2019; Version: 3.0 
Page 2 
SIGNATURES OF APPROVAL 
(redacted) 
Date 
(redacted) 
Date 
(redacted) 
Date 
(redacted) 
Date 


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Date: 09 May 2019; Version: 3.0 
Page 3  
TABLE OF CONTENTS
 
Page 
 
SIGNATURES OF APPROVAL ............................................................................................................... 2 
TABLE OF CONTENTS ........................................................................................................................... 3 
LIST OF TABLES ........................................................................................................................................ 5 
LIST OF ABBREVIATIONS ....................................................................................................................... 6 
1.0 
INTRODUCTION ...................................................................................................................... 7 
1.1 
Background .................................................................................................................................. 7 
1.2 
Objectives .................................................................................................................................... 8 
1.2.1 
Primary Objectives ....................................................................................................... 8 
1.2.2 
Secondary Objectives ................................................................................................... 8 
1.2.3 
Tertiary Objectives ....................................................................................................... 9 
1.2.4 
Leading Safety Objectives ............................................................................................ 9 
1.3 
Study Design ................................................................................................................................ 9 
1.4 
Sample Size Determination ........................................................................................................ 10 
1.5 
Randomization ........................................................................................................................... 10 
Table 1. Schedule of Assessments .......................................................................................................... 13 
1.6 
Blinding...................................................................................................................................... 14 
1.7 
Definitions .................................................................................................................................. 15 
2.0 
ANALYSIS POPULATIONS .................................................................................................. 16 
2.1 
Intent-to-Treat Population .......................................................................................................... 16 
2.2 
Safety Population ....................................................................................................................... 16 
2.3 
Per Protocol Population ............................................................................................................. 16 
3.0 
INTERIM EFFICACY ANALYSES ...................................................................................... 17 
4.0 
DATA REVIEW ....................................................................................................................... 18 
5.0 
MISSING DATA AND DATA TRANSFORMATION ........................................................ 19 
5.1 
Missing Data .............................................................................................................................. 19 
5.2 
Data Transformation .................................................................................................................. 19 
6.0 
STATISTICAL METHODS ................................................................................................... 20 
6.1 
Subject Disposition .................................................................................................................... 21 
6.2 
Protocol Deviations and Protocol Violations ............................................................................. 21 
6.3 
Treatments .................................................................................................................................. 22 
6.4 
Demographic and Baseline Characteristics ................................................................................ 23 
6.5 
Pooling of Sites .......................................................................................................................... 23 


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TABLE OF CONTENTS (continued) 
 
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Date: 09 May 2019; Version: 3.0 
Page 4  
7.0 
EFFICACY ANALYSIS .......................................................................................................... 25 
7.1 
Primary Outcome Variable Analysis ......................................................................................... 25 
7.1.1 
Primary Outcome ....................................................................................................... 25 
7.1.2 
Statistical Hypothesis ................................................................................................. 25 
7.1.3 
Primary Efficacy Analysis .......................................................................................... 25 
7.2 
Secondary Efficacy Analyses ..................................................................................................... 27 
7.2.1 
Key Secondary Outcome Analysis ............................................................................. 28 
7.2.2 
National Institutes of Health Stroke Scale.................................................................. 30 
7.2.3 
Barthel Index .............................................................................................................. 30 
7.2.4 
Mortality ..................................................................................................................... 31 
7.2.5 
Proportion of subjects with Day 90 mRS ≤ 1 ............................................................. 31 
7.3 
Tertiary Efficacy Outcomes Analyses ....................................................................................... 31 
7.3.1 
EQ-5D-5L ................................................................................................................... 32 
7.3.2 
Volume of Stroke ....................................................................................................... 32 
7.3.3 
Cognitive Outcomes ................................................................................................... 33 
7.3.4 
mRS at 30 Days .......................................................................................................... 33 
7.4 
Exploratory Analyses ................................................................................................................. 33 
7.5 
Pharmacokinetic Analyses ......................................................................................................... 35 
Table 2. Summary of Inferential Efficacy Analyses ............................................................................ 37 
8.0 
SAFETY ANALYSES ............................................................................................................. 39 
8.1 
Adverse Events .......................................................................................................................... 39 
8.2 
Vital Signs .................................................................................................................................. 40 
8.3 
Laboratory and 12-Lead Electrocardiogram Results ................................................................. 41 
8.4 
Prior and Concomitant Medications .......................................................................................... 41 
8.5 
Independent Data Monitoring Committee ................................................................................. 41 
9.0 
REFERENCES ......................................................................................................................... 44 
Table A-1: AEs Related to Angioedema (by PT) based on SMQ ......................................................... 46 
Table A-2: AEs related to Hypotension (by PT) based on MedDRA Terms ....................................... 46 
Table A-3: AEs related to Anaphylactic reaction and Anaphylactic shock (by PT) based on 
SMQs ......................................................................................................................................... 47 
 
 


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Page 5 
LIST OF TABLES 
 
Page 
 
Table 1. 
Schedule of Assessments ..................................................................................................................... 13 
Table 2. 
Summary of Inferential Efficacy Analyses ......................................................................................... 37 
 
 
 
 
 
 


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Date: 09 May 2019; Version: 3.0 
Page 6 
LIST OF ABBREVIATIONS 
 
 
AE 
Adverse Event 
AIS 
Acute Ischemic Stroke 
ANCOVA 
Analysis of Covariance 
CI 
Confidence Interval 
CRU 
Clinical Research Unit (responsible for the Electronic Data Capture system) 
CTA 
Computerized Tomographic Angiography 
CTP 
Computerized Tomographic Perfusion 
ASPECTS 
Alberta Stroke Program Early Computerized Tomography Score 
BI 
Barthel Index 
BNT 
Boston Naming Test 
DWI 
Diffusion Weighted Imaging 
ECG 
Electrocardiogram 
EMS 
Emergency Medical Services 
e-CRF 
Electronic Case Report Form 
FLAIR 
Fluid Attenuated Inversion Recovery 
ICH 
Intracerebral Hemorrhage 
ICA  
Internal Carotid Artery  
IDMC 
Independent Data Monitoring Committee 
IQR 
interquartile range 
ITT 
Intent-to-Treat  
MedDRA 
Medical Dictionary for Regulatory Activities 
MCA  
 Middle Cerebral Artery 
MoCA 
Montreal Cognitive Assessment 
MRP 
Magnetic Resonance Perfusion 
mRS 
Modified Rankin Scale 
NCCT 
Non-contrast Computed Tomography Scan 
NIHSS 
National Institutes of Health Stroke Scale 
O-F 
O’Brien-Fleming 
PP 
Per Protocol 
SAE 
Serious Adverse Event 
SD 
Standard Deviation 
SNAP 
Sunnybrook Hemispatial Neglect Procedure 
SOC 
System Organ Class 
TEAE 
Treatment-emergent Adverse Event 
mTICI 
Modified Thrombolysis in Cerebral Infarction scale 
tPA 
Tissue Plasminogen Activator 
 
 


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Page 7 
1.0 
INTRODUCTION 
This document provides the details of statistical analyses planned for Protocol No. 
NA-1-007.  In addition, it discusses the statistical issues relevant to these analyses 
(e.g., sample data to be used and missing data). 
1.1 
Background 
NA-1 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 NA-1. The ability to identify patients with 
salvageable brain using the criteria used in the ESCAPE trial[2] provides an 
opportunity to target patients who may have the greatest benefit from neuroprotection, 
and to enhance further the impact of reperfusion therapies.[3] Our preclinical and 
clinical data support this notion. 
The rationale for this study is as follows: 
1. 
There is no convincing evidence from randomized controlled trials that 
neuroprotection can be of clinical benefit to patients with AIS.   There is however, 
extensive preclinical evidence that neuroprotection is of greatest benefit for 
improving functional outcome in studies employing experimental animal stroke 
models in which stroke is followed by reperfusion, as compared with stroke 
models in which arterial vessel occlusion is undertaken without reperfusion. 
2. 
The neuroprotectant, NA-1, has been demonstrated to be highly effective in 
reducing stroke size and improving the functional outcome of experimental 
animals subjected to acute stroke, including rats and primates. NA-1 is more 
effective in reducing infarct size and improving functional outcome in models of 
ischemia-reperfusion, as compared with permanent arterial occlusion.[4, 5] 


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3. 
NA-1 has an excellent safety profile in preclinical animal studies, a human Phase 
1 trial, and a human Phase 2 study (the ENACT trial),[6] Patients in the ENACT 
trial were also individuals who were being subjected to an endovascular 
procedure (intracranial aneurysm repair) and to treatment with NA-1 or placebo. 
4. 
The ESCAPE and other recent trials of endovascular thrombectomy for AIS have 
demonstrated that modern acute endovascular therapy can rapidly recanalize 
blocked major arteries in patients with acute stroke arising from large artery 
occlusion with a low complication rate and high complete reperfusion rates.[2, 7-9] 
This paradigm replicates the preclinical animal ischemia-reperfusion models in 
which neuroprotectants have the highest demonstrated efficacy.  
5. 
NA-1 has shown promising results in reducing ischemic brain damage in humans 
having demographics similar to those of stroke patients.[6] 
6. 
There is a compelling need to develop neuroprotectants in order to increase the 
proportion of patients who may benefit from recanalization therapies. These 
agents could improve the outcomes of those who receive endovascular 
recanalization and make more patients into candidates for endovascular or 
pharmacological recanalization treatment.  
1.2 
Objectives 
1.2.1 
Primary Objectives 
The primary objective is to determine the efficacy of the neuroprotectant, NA-1, in 
reducing global disability in subjects with major acute ischemic stroke (AIS) with a 
small established infarct core and with good collateral circulation who are selected for 
endovascular revascularization. 
1.2.2 
Secondary Objectives 
The secondary objectives are to determine the efficacy of NA-1 in: 
• 
Reducing functional dependence 
• 
Improving neurological outcome 
• 
Improving activities of daily living 
• 
Reducing mortality rate 


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1.2.3 
Tertiary Objectives 
The tertiary objectives are to determine the efficacy of NA-1 in: 
• 
Improving health-related quality of life. 
• 
Decreasing infarct volume at follow-up imaging 
• 
Improving cognitive function 
1.2.4 
Leading Safety Objectives 
The leading 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 (IV) infusion of NA-1 to 
subjects with acute stroke who are selected for endovascular revascularization on the 
incidence of serious adverse events (SAEs) and 90-day mortality. 
1.3 
Study Design 
This is a Phase 3 randomized, multicenter, blinded, placebo-controlled, parallel group, 
single-dose design. Per inclusion/exclusion criteria, subjects suffering an acute stroke 
who are selected for endovascular revascularization in accordance with local 
institutional practices and who present with a small established infarct core with good 
collateral circulation, will be given a single, 2.6 mg/kg (up to a maximum of 270 mg) 
intravenous dose of NA-1 or placebo. Ideally, dosing should begin within 30 minutes 
of randomization and within 60 minutes of the NCCT.  
A total of 1120 subjects aged 18 years and older will be enrolled into the study. A 
patient who consents but is not randomized will be considered a screen failure. A 
subject is considered randomized the moment the randomization process is completed 
on-line. This is time “0” for the study. 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 study is defined 
as the date that the last enrolled subject has completed their Day 90 visit. 
The Schedule of Assessments is presented in Table 1. 


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1.4 
Sample Size Determination  
Assuming a 52% overall responder rate for the placebo group, there will be 81.7% 
power to detect an 8.7% absolute effect difference between response rate (proportion 
of responders, with Day 90 mRS in the range 0 to 2) with NA-1 and placebo, at alpha 
level 0.05, 2-sided with a planned sample size of 1076 evaluable subjects, randomized 
1:1, per group, accounting for a single interim analysis when 600 subject have reached 
their primary endpoint assessments, with O’Brien-Fleming alpha-spending function 
(EaST® V6.3) stopping boundary for overwhelming efficacy and a non-binding 1% 
conditional power futility stopping boundary. (See Section 3.0 for further details on the 
interim analysis.) The sample size will be inflated approximately 4% to N= 560 per 
group to account for loss-to-follow-up and dropouts.  
1.5 
Randomization 
Treatments (placebo vs. NA-1) will be assigned 1:1 by application of a stratified 
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 within 30 minutes post-randomization and within 60 minutes of the NCCT. 
Although each vial of NA-1 or placebo will have a unique ID 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 receiving different 
combinations of adjunct thrombolytic and thrombectomy therapies, randomization will 
be stratified by (1) intravenous thrombolysis with alteplase (yes/no) and by (2) a 
subject’s initial thrombectomy approach (stent retriever vs. thrombus aspiration 
device). Planned initial use of any other endovascular device type or intra-arterial 
medications will constitute an exclusion criterion. Similarly, if intravenous 
thrombolysis is planned for the subject, use of any intravenous thrombolytic other than 
alteplase is an exclusion criterion. Thus, there will be 4 randomization strata: 
a. Alteplase+stent retriever 
b. Alteplase+thrombus aspiration device 


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c. Stent retriever without Alteplase 
d. Thrombus aspiration device without Alteplase 
Randomization will be by the minimally sufficient minimization procedure of Zhao.[10] 
The procedure will be implemented to achieve balance on 6 baseline subject-level 
prognostic variables: age, sex, baseline NIHSS scores, baseline ASPECTs score, 
occlusion location and study site. At the time of randomization, subject age will be 
calculated against the central server date and time, which will be synchronized weekly 
to the Denver atomic clock. This overall approach will ensure that the subjects entered 
into the trial will be matched on the six key prognostic covariates, within strata and 
between treatment arms, thereby minimizing likelihood of chance confounding of 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 40 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 
printed from the randomization website and it will be transmitted to the central database 
to create the case in the electronic case report form (e-CRF).  The randomization date, 
time and the two stratification variables, and the 6 covariates for the minimization 
algorithm will not be editable once the subject is randomized. Once a subject is entered 
into the randomization website, that subject’s e-CRF will be auto-created and ready for 
data entry. 
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 
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Re-stocking will take place within one business day 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 1. 
Schedule of Assessments 
++ 
Baseline 
Post- EVT 
(~2 h) 
Day 1 
(24 ± 12 h 
from 
random- 
ization) 
Day 2 
(48 ± 8 h from 
randomization) 
Day 5 or 
discharge 
(±1 d) 
Day 30 (±5 
d) 
Day 
90 (±14 d) 
Informed consent 
X 
 
 
 
 
 
 
Attempt at regained capacity 
informed consent★ 
 
 
X 
X 
X 
X 
X 
History and examination 
X 
 
 
 
 
 
 
Weight 
X*  
 
 
 
X (Actual) 
 
 
Vital Signs (BP, HR, Temp) 
★★ 
X 
X 
X 
X 
X 
 
 
Randomization/ Study drug 
administration 
X 
 
 
 
 
 
 
Mortality 
 
 
 
 
X 
X 
X 
NIHSS 
X 
X 
X 
X 
X 
X 
X 
mRS 
 
 
X¶ 
 
X 
X 
X 
Barthel Index 
X 
 
 
 
 
X 
X 
BNT15, SNAP, MoCA¶¶ 
 
 
 
 
 
 
X 
EQ-5D-5L 
 
 
 
 
 
X 
X 
NCCT head 
X 
 
 
 
 
 
 
CTA (Circle of Willis) 
X 
 
 
 
 
 
 
Endovascular Procedure 
X 
 
 
 
 
 
 
MR head 
 
 
X** 
 
 
 
 
CBC, electrolytes, INR, aPTT, 
serum creatinine and serum 
glucose 
X‡ 
 
X 
 
 
 
 
Pregnancy test 
X‡‡ 
 
 
 
 
 
 
Immunogenicity sample‡‡‡ 
 
 
X 
 
 
X 
 
Pharmacokinetic samples‡‡‡‡ 
X 
 
 
 
 
 
 
ECG 
X‡ 
 
X 
 
 
 
 
AE assessment 
Collected to Day 30 visit 
 
SAE assessment 
Collected to Day 90 visit 
Prior medications 
X§§ 
 
 
 
 
 
 
Concomitant medications 
Collected to Day 30 visit 
 
★ 
If the original process involved anyone other than the subject (and if required), site staff will make ongoing efforts until (1) regained capacity 
consent is obtained from subject, (2) death, or (3) completion of the Day 90 assessment. 
★★ 
Vital signs (BP, HR only) should be recorded immediately before and after completion of the study drug infusion, temperature will be 
taken at baseline per standard of care .¶ 
Historical (pre-stroke) score 
¶¶ 
Assessments will be conducted only if the tool/scale is available in local language. 
*  
At baseline estimated or actual weight 
** 
Day 1 MR head may be supplanted by an NCCT head if MR is unavailable or contraindicated. 
‡ 
ECG testing and Blood should be drawn at baseline, but results are not required prior to randomization. For ECG, if treating physician deems 
that pre-treatment ECG impedes access to timely care, ECG must be completed within 6 hours of randomization. 
‡‡ 
If the subject 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 
‡‡‡ 
Immunogenicity samples will be taken from a subset of up to 250 subjects at Canadian and US sites. 
‡‡‡‡  PK samples will be taken from up to 100 subjects at a subset of Canadian and US sites.  Samples will be taken at pre-dose and at 10, 20, 30, 
60 and 120 min after the start of drug administration. 
§§ 
Prior medications should be documented but their documentation not required prior to randomization.  
d = days; h = hours 
 


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1.6 
Blinding  
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 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 a group that is independent of the sponsor 
and blinded project team implementing the trial. A firewall will be maintained between 
the IDMC (unblinded) and the project staff (blinded).  The IDMC will review safety 
data throughout the trial on an ongoing basis, 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 in 
the event that 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 ESCAPE-NA1 CRU center to 
request unblinding of the specific subject. The CRU 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 files. 


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1.7 
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. 
Prior and Concomitant Medications: Prior medications are defined as those taken 
within three days of treatment initiation. Concomitant medications are defined as those 
taken during study drug administration or after study drug has been administered 
through and including the Day 30 visit. All prior and all concomitant medications will 
be recorded on the electronic case report form (e-CRF).  
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. 
Treatment-Emergent Adverse Event: A treatment-emergent adverse event (TEAE) 
is one that first occurs or worsens in severity or frequency after study drug has been 
administered through to and including the Day 30 visit.  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 and the AE in question occurs 
concurrently or subsequent to the study drug administration, 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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2.0 
ANALYSIS POPULATIONS 
2.1 
Intent-to-Treat 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 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 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 meet the criteria for a “major protocol deviation”.. 


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3.0 
INTERIM EFFICACY ANALYSES 
An efficacy interim analysis after approximately 600 subjects complete the Day 90 
follow-up (~56% information) will be conducted by the unblinded statistician in the 
independent Statistical Group (ISG) using the alpha spending function method[11] with 
O’Brien and Fleming[12] type stopping boundary for efficacy and a non-binding 
conditional power boundary (based on the observed trend at the interim analysis) for 
futility. Overwhelming efficacy at the interim analysis would occur if the test statistic 
crosses the O-F superiority boundary. For an interim analysis conducted at exactly 
55.8% information, the superiority critical p-value for stopping (boundary value) would 
be 0.003 and that at the end of the study (primary analysis) would be 0.024, 1-sided. 
Conversely if the conditional power estimate based on the observed trend at the interim 
is <1% the trial may be deemed to be futile, contingent on consideration of other safety 
and efficacy factors (i.e., the futility boundary is nonbinding).  
The IDMC may recommend stopping for futility at the interim analysis if the test 
statistic crosses the O-F or conditional power boundary.  However, notwithstanding the 
O-F superiority critical p-value of 0.003 for stopping (boundary value) at the interim 
analysis of the primary efficacy outcome, the IDMC will be instructed that it should 
not recommend to stop the trial for overwhelming efficacy unless otherwise instructed 
by the Steering Committee at the Open Session of the IDMC meeting. The IDMC 
Charter will provide further details on the rationale for, and how, these 
recommendations will be communicated. 
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 subject blind to 
results by treatment assignment during the study. Firewalls will be in place at the 
Statistical Group preparing all interim reports to protect and sequester all interim results 
on safety and efficacy 
 
 


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4.0 
DATA REVIEW 
Relevant past medical history as well as prior and concomitant medications will be 
listed. AEs will be coded using the Medical Dictionary for Regulatory Activities 
(MedDRA) to assign a system organ class (SOC) and preferred term to each AE. 
When the database has been declared complete and accurate, the database will be 
locked and subsequently unblinded. 
 
 


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5.0 
MISSING DATA AND DATA TRANSFORMATION 
5.1 
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. This was kept to a minimum of 1.3% in the ESCAPE 
trial.[2] Deceased subjects will be assigned scores of 6 on the mRS, 42 on the NIHSS, 
0 on the Barthel Index and be counted as non-responders. For the primary analysis for 
regulatory submission, we will assume that subjects who are missing the primary 
endpoint data will be considered non-responders. If more than 5% of subject 
randomized are missing the primary endpoint, two sensitivity analyses will be 
employed to examine alternatives to this extreme single-value imputation: (1) multiple 
imputation of the ordinal mRS score which will then be converted to the corresponding 
binary score; and (2) if, as expected, ≤ 5% of the mRS data are missing, a completers’ 
analysis. 
5.2 
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 can be normalized 
with an inverse cubic root transformation. Alternate Box-Cox power transformations 
may be required, depending upon the data distribution (note: the inverse cubic root 
transformation is a member of the Box-Cox power series).  No data transformation is 
planned for the primary analysis. 


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6.0 
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; 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 2-sided 
hypothesis tests performed at the 0.05 level of significance. 
In order to protect the overall trial false positive rate, the primary efficacy analysis, key 
secondary outcome analysis and secondary endpoints 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 outcome 
2. 
Key secondary outcome analysis (shift analysis using proportional odds model); 
3. 
Secondary efficacy endpoints, as specified in the order presented below in 
Section 6.7. 


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All data will be included in subject data listings for all randomized subjects.  
A final, unblinded, statistical report that will include both efficacy and safety 
evaluations will be generated upon completion of the trial. The final report will be 
distributed to the Trial Steering Committee 
6.1 
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. 
In addition, a tabulation of the number and percentage of subjects randomized will be 
summarized by site for the ITT population. 
6.2 
Protocol Deviations and Protocol Violations 
The case report form pre-specifies the major protocol violations and protocol 
deviations.  The data will be reviewed regularly to identify both.  Major protocol 
deviations will be determined during a data review meeting prior to database lock. 
These may include but may not be limited to: 
• 
Enrollment did not comply with inclusion criteria 
• 
Enrollment did not comply with exclusion criteria 
• 
Consent not obtained. 
• 
Subjects who did not receive a per-protocol dose (none or incomplete dose), or 
received an incorrect study drug vial, or received the study drug infusion over 15 
or more minutes. 
The number and percentage of subjects in the ITT population with protocol violations 
will be summarized by treatment group and overall. 


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6.3 
Treatments 
Per protocol, an IV solution of 20mg NA-1/ml will be given to subjects with a body 
weight < 105 kg to achieve a final target dose of 2.6 mg NA-1/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).  However, per-protocol, at the time of dosing, the 
total dose is based on the subject’s estimated weight if an exact weight is not available.  
A second weight, using an in-hospital scales, will be obtained by day 5 or discharge 
(±1 d). Discrepancies between the weight estimate and actual weight obtained using in-
hospital scales may result in some subjects weighing >105 Kg receiving less than 270 
mg, and some subjects weighing < 105 Kg receiving the full 270 mg dose. Study drug 
monitors at each site will record the total volume of NA-1 solution received by each 
subject and their estimate of body mass at the time of treatment.  Two measures of 
subjects’ NA-1 exposure and 4 additional subject-level measures of the timeliness of 
the interventions will be computed as follows.   
1. Number subjects who received any NA-1 
2. Descriptive statistics for: 
a. Time from randomization to start of NA-1 infusion 
b. Time from NCCT to start of NA-1 infusion 
c. Subject’s Actual exposure (mg NA-1/kg body wt) =  
      [(20mg NA-1/ml of IV solution)*ml dose received]/kg body wt, where “kg 
body weight” was obtained using an in-hospital scale. 
d. Subject’s Relative exposure (%) = 
      (Actual exposure*2.6 mg NA-1/kg body wt) *100. where “kg body weight” was 
obtained using an in-hospital scale. 
e. Time from NCCT to 1st recanalization  
f. Time from NCCT to arterial access puncture 
An additional 7 measures of overall dosing compliance and timeliness of intervention, 
at the treatment group level, will be computed from the subject-level measures and 
reported as percentages of the number of subjects in each treatment arm who received 
NA-1 therapy or placebo. 
3. 
Overall relative NA-1 dosing compliance (%)= 100*[A+B]/C where A = number 
of subjects who received 2.6 mg NA-1/kg body wt; B = number of subjects who 
received 270mg total dose; C = number of subjects who received any amount of 
NA-1. As dosing compliance (per protocol) is the subject of this calculation, “kg 


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body wt” in this instance will be the weight (actual or estimated) obtained at the 
time of dosing.  
4. 
Speed of intervention metrics measured on NA-1 and placebo treated subjects (% 
of each treatment group): 
a.  % of subjects with time from randomization to NA-1 or placebo infusion < 30 
minutes 
b. % of subjects with time from NCCT to infusion with NA-1 or placebo 
infusion < 60 minutes 
c. % of NA-1 and placebo subjects with time from NCCT to recanalization < 75 
minutes 
d.  % of NA-1 and placebo subjects with time from NCCT to recanalization < 90 
minutes 
e. % of NA-1 and placebo subjects with time from NCCT to arterial access 
puncture <45 minutes 
f. % NA-1 and placebo subjects with time from NCCT to arterial access 
puncture <60 minutes 
All measures will be summarized separately for the ITT, PP, and safety populations; 
individual exposures and speed of intervention times will be listed by treatment arm 
and subject.   
6.4 
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: prior use of 
alteplase (tPA), intended first thrombectomy approach (stent retriever or thrombus 
aspiration device), baseline NIHSS score, baseline ASPECTS score, occlusion 
location, and site. The summaries will be provided for both the ITT and Per Protocol 
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 two stratification variables “alteplase use” (yes/no), and “first declared 
thrombectomy device” (stent retriever / aspiration device) in order to assess balance 
across treatment groups. 
6.5 
Pooling of Sites 
In order to avoid sparse sites (sites with fewer than 5 randomized subjects) and the 
potential for too many levels for the explanatory variable of “site”, sites within a 


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geographic region (Canada/USA/Rest of World) with fewer than 5 randomized subjects 
will be pooled into a single pooled site for use in efficacy analyses. If a resulting pooled 
site still has fewer than 5 randomized subjects, it will be further pooled with the smallest 
remaining unpooled site from that geographic region. If the resulting pooled site still 
has fewer than 5 randomized subjects, it will be further pooled with the smallest pooled 
site from another geographic region. This pooling is estimated to make up 
approximately 15% of all enrolled subjects by the time that the first 600 subjects will 
have been enrolled.  
 


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7.0 
EFFICACY ANALYSIS 
Efficacy analyses are summarized in Table 2. 
7.1 
Primary Outcome Variable Analysis 
7.1.1 
Primary Outcome 
The primary endpoint used in this trial will be global disability as measured by the mRS 
at Day 90. Scores for the mRS range from 0 to 6, with 0 indicating no residual 
symptoms; 5 indicating bedbound, requiring constant care; and 6 indicating death. The 
mRS will be obtained at Day 5 (or discharge) and Days 30 and 90. Premorbid mRS 
status will also be obtained retrospectively at 24 hours.  
 
The primary efficacy analyses will be conducted in 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. The primary endpoint used in this trial will be global disability, 
as measured by the mRS, at Day 90. 
7.1.2 
Statistical Hypothesis 
The primary hypothesis is: 
H0: πNA-1 = πplacebo VS 
Ha: πNA-1 ≠ πplacebo 
Where πNA-1 and πplacebo are the NA-1 and placebo population proportions of responders, 
defined as subjects whose Day 90 mRS score is ≤ 2. 
7.1.3 
Primary Efficacy Analysis 
The primary efficacy outcome is the overall proportion subjects experiencing a 
favorable functional outcome 90-days post-randomization; where favorable is defined 
as a mRS score of 0, 1, or 2. Subjects with favorable functional outcomes are defined 
as responders. Subjects missing the day 90 primary assessment for any reason will be 
considered non-responders for the primary analysis. 


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The primary hypothesis to be tested is that administration of NA-1 will result in an 
increase in the proportion of responders (as defined by a score of 0-2) at Day 90. The 
primary analysis will be a Wald test for treatment group difference in the primary 
outcome from a logistic regression adjusted for the 2 stratification variables 
(alteplase use, first declared thrombectomy device), and the 6 covariates used in the 
minimization (age, sex, baseline NIHSS score, baseline ASPECTS score, occlusion 
location, and site). This 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 following SAS PROC LOGISTIC code will be implemented for the binary primary 
endpoint analysis: 
 proc logistic data=adqs; 
   where ittfl = ’Y’ and qstest = ’mRS (binary)’; 
   class occloc alteplase thromb_app site  
         trtp(param=ref ref='Placebo') ; 
   model mRS = age sex blnihss blaspect occloc   
               alteplase*thromb_app site trtp; 
   oddsratio trtp;  
run; 
 
Where mRS is the binary independent functioning score made by dichotomizing mRS 
at 2: mRS≤2 = independent functioning. Occloc is the occlusion location (MCA vs. 
ICA), blnihss is the baseline NIHSS score (0-42), blaspect is the baseline ASPECTS 
score (0-10), alteplase is an indicator for having received IV alteplase treatment, 
thromb_app is the thrombectomy approach (stent retriever vs. aspiration device), 
alteplase*thromb_app is a 4-level stratification, site is investigative site, sex and age 
are subjects’ sex (male/female) and age (years) at study entry, and trtp is the planned 
treatment.  
All odds ratios (with Wald 95% C.I.s) and corresponding Wald test statistics will be 
summarized in a table, by select subpopulations. Actual proportions with and without 
independent functioning will be reported as will the proportions in each of the ordinal 
mRS categories. 


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Three supportive 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. 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 NA-1 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 ESCAPE trial.[2] (3) The primary analysis will be repeated on the 
PP population using actual first endovascular approach (instead of declared approach).  
7.2 
Secondary Efficacy Analyses  
Descriptive summaries will be provided for each secondary endpoint in the ITT 
population. As with the primary endpoint, secondary endpoint analyses will also 
generally be adjusted for both the stratification variables and covariates used in the 
minimization algorithm. 
All tests will be conducted with two-sided level of significance alpha = 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, key secondary analysis second, etc.), after the 
first test which fails. All tests that follow the first failed test, are considered exploratory. 
For the purpose of clarity, since the key secondary 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 tests will still be considered to be protected. 
The secondary endpoints, and the order they are to be tested, are: 
1. 
Shift to reduced functional dependence analyzed across the whole distribution of 
scores on the mRS at Day 90 or the last rating. 


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2. 
Proportion of subjects with good neurological outcome, as defined by a score of 
0-2 vs 3 or greater on the NIHSS at Day 90 or the last rating. 
3. 
Proportion of subjects with functional independence in activities of daily living, 
as defined by a score of ≥ 95 vs 0-90 on the Barthel Index at Day 90 or the last 
rating. 
4. 
The proportions of control and NA-1 treated subjects who die by study day 90. 
5. 
The proportion of subjects with mRS score of 0-1 at Day 90. 
7.2.1 
Key Secondary Outcome Analysis 
A key secondary 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 NA-1 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 odds ratio (95% C.I.). 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. A covariate-adjusted POM will be used to 
derive the common odds of improvement (i.e. the NA-1 vs. placebo “shift” in mRS 
score distributions). Model covariates will include all of the variables in the 
minimization algorithm, both stratification variables and covariates.  
The following example SAS code can be used to fit the POM to the subjects’ mRS 
score: 
ODS graphics on; 
proc logistic data=adqs; 
   where ittfl = ’Y’ and qstest = ’mRS (Ordinal)’;   
   class occloc alteplase thromb_app site  
         trtp(param=ref ref='Placebo') ; 
   model mRS = age sex blnihss blaspect occloc   
               alteplase*thromb_app site trtp;  
   effectplot interaction(x=trtp sliceby=mRS)/polybar;        
   oddsratio trtp;  
run; 
 


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Where “mRS’ is the collapsed mRS scale values ranging from 0 to 5 (level 5 = 5+6 
mRS combined), “occloc” is the occlusion location  (ICA vs. MCA), “blnihss” is the 
baseline NIHSS score (0-42), “blaspect’ is the baseline ASPECTS score (0-10), 
‘alteplase’ is an indicator for having received IV alteplase treatment, thromb_app is the 
thrombectomy approach (stent retriever vs. aspiration device), alteplase* thromb_app 
is a 4-level stratification, “site” is investigative site, subject sex and age are the 
subjects’ sex and age at study entry, and “trtp” is the planned treatment (NA-1, 
placebo).  
When SAS fits the POM, it runs a global test for a shift across all 6 mRS categories in 
the NA-1 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:  
a. The proportion of subjects with mRS = 0 vs. the proportion with mRS>0 
b. The proportion of subjects with mRS ≤ 1 vs. the proportion with mRS>1 
c. The proportion of subjects with mRS ≤2 vs. the proportion with mRS>2 
d. The proportion of subjects with mRS ≤3 vs. the proportion with mRS>3 
e. 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 an NA-1-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. 
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 


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common dichotomous mRS analyses that efficacy decisions in stroke trials are often 
based on (Agresti 2007; Nunn 2016).[13, 14] 
The results of the PO assumption tests, the common odds ratio estimate (with Wald 
95% C.I.s) 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. 
In the event that the test of the PO assumption, needed to proceed with the key 
secondary efficacy analysis described, determines that the assumption is invalid, this 
analysis will not be conducted and remaining secondary endpoints to be tested as listed 
in Section 7.2.2 to 7.2.5 will still be considered to be protected (overall trial alpha still 
controlled). 
7.2.2 
National Institutes of Health Stroke Scale 
The NIHSS is a standardized neurological examination score, with scores ranging 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), 24 and 48 Hours, Day 5 or discharge, and Days 30 and 
90.  
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 in NA-1 versus placebo control 
subjects will be compared using the same logistic regression model as in the primary 
efficacy analysis. Results will be summarized and tabulated. 
7.2.3 
Barthel Index  
The BI is an index of functional independence with scores ranging 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) and on Days 30 and 90.  Note that the 
original Barthel Index was a scale from 0-20, but this study will use the modified 
version.  The modified Barthel index simply multiplies the original scale by 5. 


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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 NA-1 
versus placebo control subjects will be compared using the same logistic regression 
model as in the primary efficacy analysis. Results will be summarized and tabulated. 
7.2.4 
Mortality  
Mortality will be assessed at Day 5 or discharge and at Days 30 and 90. Mortality rates, 
defined as the number of deaths observed divided by the number of subjects observed 
over the 90-day study period between NA-1 and placebo control subjects, will be 
analyzed by the same logistic regression model as in the primary efficacy. Subjects 
with missing outcomes will be treated as deaths for this analysis. The odds ratio 
associated with the treatment effect, adjusted for the stratification and covariates as 
described for the primary endpoint analysis, will be presented with a 95% confidence 
interval and the associated Wald test. 
7.2.5 
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 NA-1 versus placebo 
control subjects will be compared using the same logistic regression model as in the 
primary efficacy analysis. Results will be summarized and tabulated.  
7.3 
Tertiary Efficacy Outcomes Analyses 
Summary statistics for each tertiary efficacy endpoint will be tabulated by treatment 
group. The tertiary analyses will be considered exploratory. The tertiary efficacy 
endpoints include the: 
• 
Health-related quality of life, as measured by the EQ-5D-5L at Day 90 or the last 
rating. 
• 
Volume of acute stroke as measured by a) DWI and b) FLAIR at 24 Hour follow-
up. If NCCT was done instead of MRI, Volume of stroke will be derived from 
hypodense areas. 


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• 
Cognitive outcomes, as measured by the 15-item Boston Naming Test (BNT15), 
Sunnybrook Hemispatial Neglect Procedure (SNAP) and the Montreal Cognitive 
Assessment (MoCA). 
• 
The proportion of subjects experiencing a favorable functional outcome 30 days 
post-randomization, defined as 0 to 2 on the mRS. 
7.3.1 
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/Depression. Each 
dimension has five response categories corresponding to no problems, slight, moderate, 
severe and extreme problems. The instrument is designed for self-completion, and 
respondents rate their overall health on the day of the interview on a 0-100 
hash-marked, vertical visual analogue scale (EQ-VAS). The EQ-5D-5L will be 
completed at Day 30 and Day 90. 
For the EQ-5D-5L, the difference between NA-1 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 NA-1/placebo treatment indicator variable and 
the 7 stratification variables and covariates used in the primary and secondary efficacy 
analyses. ANCOVA results will be summarized in a table. 
7.3.2 
Volume of Stroke 
All subjects will undergo a follow-up brain MRI [including a minimum of axial DWI, 
gradient-echo (GRE), FLAIR] at 24 ± 12 hours from the time of randomization.  The 
24-hour MR is considered a standard of care imaging procedure; if MR is unavailable, 
then NCCT is allowed. The 24 hour MR (and where MR is unavailable, CT) will be 
used to assess 24 Hour infarct volume. Infarct volume determinations will not be 
conducted until after database lock. 
The total volume of new a) DWI and b) FLAIR lesions in NA-1 versus placebo control 
subjects will be calculated from the 24-hour imaging. Where MR is not available, 
infarct volumes will be determined from the 24-hour CT scan. The plan for combining 
CT and MRI data will be detailed in the imaging adjudication charter. Total volume 


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will be assessed using a linear regression using a cubic root transformation if needed. 
An ANCOVA will be fit and summarized as per the EQ-VAS model. 
7.3.3 
Cognitive Outcomes 
These will be explored using the BNT15, SNAP and the MoCA scores. The BNT15 is 
a widely used neuropsychological assessment tool to measure confrontational word 
retrieval in individuals with aphasia or other language disturbance caused by various 
neurological disorders. The SNAP is a short bedside battery for visuoconstructive 
hemispatial neglect. The MoCA has been found to be a feasible global cognitive 
screening tool in stroke trials.  
The BNT15 (short form), SNAP and MoCA will be administered at Day 90.  
Assessments will only be conducted if the tool/scale is available in the local country 
language.  If the assessment is not conducted for language reasons the outcome will not 
be measured for those subjects. 
BNTP (scale=0-15) and SNAP total scores (scale=0-100) will be analyzed and 
summarized as continuous endpoints using the basic ANCOVA models described in 
the two previous sections. As is standard practice, the MoCA scores (0-30) will be 
dichotomized at 26 and analyzed in the same type of logistic regression model as has 
been described for the primary endpoint. MoCA scores ≥ 26 are considered to indicate 
normal cognition (Nasreddine, 2005, Smith, 2007).[15, 16] Results will be summarized 
and tabulated as in the primary efficacy analysis.   
7.3.4 
mRS at 30 Days 
The proportion of subjects experiencing a favorable functional outcome 30 days 
post-randomization, defined as 0 to 2 on the mRS, will be analyzed in the same type of 
logistic regression model as the primary endpoint. Results will be summarized and 
tabulated as in the primary efficacy analysis. 
7.4 
Exploratory Analyses 
In addition to the primary and secondary analyses adjusting for age, sex, baseline 
NIHSS score, baseline ASPECTS, intravenous alteplase, declared first device, 
occlusion location and site, exploratory subgroup analyses will be conducted to 


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determine whether any of these factors can modify the effect of the NA-1 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:   
1. 
Age > 80 years of age 
2. 
Sex (men vs. women) 
3. 
Treatment with intravenous alteplase (yes/no) 
4. 
Treatment by first declared thrombectomy device (Stent vs. Aspiration) 
5. 
Subjects whose time from onset of stroke symptoms to NA-1 (or placebo) 
treatment was ≤ 6 hrs vs. > 6 hours.  
6. 
Severe stroke defined as NIHSS > 20 vs. NIHSS <= 20. 
7. 
Outcomes by recognized ethnic and racial groups. 
8. 
Outcomes by degree of reperfusion (TICI ≥ 2b vs. TICI <2b) 
9. 
General anesthesia vs. no general anesthesia 
10. Baseline occlusion location (MCA vs. ICA) 
11. Subjects whose time from onset of stroke symptoms to NA-1 (or placebo) 
treatment was ≤ 4 hrs vs. > 4 hours.  
12. Subjects weighing between 105-120 kg. 
13. ASPECTS score of 5-7 vs. 8-10 
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 endpoint, 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 


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and a second model will be fit to females). The estimated (NA-1/placebo) odds ratios, 
with 95% confidence intervals will be the NA-1 effect size estimates for each of the 
subgroups (e.g., for males and for females) and will be displayed in the forest plots.  
An additional exploratory analysis will consider the time from administration of tPA 
to infusion start and its effect on the primary efficacy outcome. This will be assessed 
by performing the logistic regression for the primary efficacy outcome, with an 
additional term added for the time interval between tPA administration and start time 
of infusion. This time may be positive or negative, depending on whether tPA 
administration or infusion occurred first, although it is expected that most subjects will 
receive tPA before drug infusion. The time should be calculated as “start time of drug 
infusion” minus “time of tPA administration”. 
In addition to the subgroup analyses described above, the analyses of the primary and 
secondary endpoints will be repeated with additional terms for period (e.g., before/after 
100-subject IDMC; before/after 300-subject IDMC; before/after 600-subject IDMC) 
and period by treatment interaction. Simple effects within period and the interaction of 
treatment with period will be viewed to assess the homogeneity of the study data across 
periods before and after the various IDMC meetings. Also, the percentage of patients 
with functional independence at 90 days as defined by a 90 day mRS of 0-2 will be 
plotted against the time from stroke symptom onset to the time of study drug 
administration for each of NA-1 and placebo.  
7.5 
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 NA-1 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 
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• 
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 NA-1 will be excluded from analysis (placebo).  
Descriptive statistics will be calculated for NA-1 plasma concentrations and for all PK 
parameters (AUC0-t, AUC0-∞, Cmax, Tmax, t½). 
A further analysis of the effect of administration of thrombolytic therapy (alteplase) 
on the pharmacokinetics of NA-1 will also be performed. 
Depending on the ability to obtain an adequate number of PK samples, the SAP may 
be amended (providing that no unblinding of treatment allocation has taken place) to 
optimize the PK analysis, including the possibility of popPK analyses in the event that 
only sporadic samples are obtained from subjects due to operational limitations. 
 


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Table 2. 
Summary of Inferential Efficacy Analyses  
Endpoint 
Type 
Endpoint 
Scale 
Population 
Statistical  Model 
Primary 
Day-90 mRS 
Binary 
(≤2 vs. >2) 
ITT  
logit(binary mRS) modeled as a function of treatment, baseline ASPECTS, occlusion location, age, sex, 
baseline  NIHSS, alteplase*thromb_app, study site     
 
Day-90 mRS 
Binary 
(≤2 vs. >2) 
PP 
logit(binary mRS) modeled as a function of treatment, baseline ASPECTS, occlusion location, age, sex, 
baseline NIHSS, alteplase*thromb_app, study site     
 
Day-90 mRS 
Binary 
(≤2 vs. >2) 
ITT,  re-
randomization 
logit(binary mRS) modeled as a function of treatment, baseline ASPECTS, occlusion location, age, sex, 
baseline NIHSS, alteplase*thromb_app, study site; run model on 5,000 re-randomized ITT populations 
 
Day-90 mRS 
Binary 
(≤2 vs. >2) 
PP 
logit(binary mRS) modeled as a function of treatment, baseline ASPECTS, occlusion location, age, sex, 
baseline NIHSS, alteplase*(actual first endovascular approach), study site     
Secondary 
Day-90 mRS 
Ordinal  
(0-4,5+6) 
ITT 
mRS cumulative logits modeled as a function of treatment, baseline ASPECTS, occlusion location, age, 
sex, baseline NIHSS, alteplase*thromb_app, study site     
 
Day-90 NIHSS 
Binary 
(≤2 vs. >2) 
ITT 
logit(binary NIHSS) modeled as a function of treatment, baseline ASPECTS, occlusion location, age, 
sex, baseline NIHSS, alteplase*thromb_app, study site     
 
Day-90 Barthel 
Binary 
(<95 vs.≥95) 
ITT 
logit(binary Barthel Index) modeled as a function of treatment, baseline ASPECTS, occlusion location, 
age, sex, baseline NIHSS, alteplase*thromb_app, study site     
 
Day-90 Mortality 
Binary day-90 
death status 
ITT 
logit(binary death status) modeled as a function of treatment, baseline ASPECT, occlusion location, age, 
sex,  baseline NIHSS, alteplase*thromb_app, study site     
 
Day-90 mRS 
mRS Binary 
(≤1 vs. >1) 
ITT 
logit(binary mRS) modeled as a function of treatment, baseline ASPECTS, occlusion location, age, sex,  
baseline NIHSS, alteplase*thromb_app, study site     
Tertiary 
EQ-VAS 
0-100 
ITT 
EQ-VAS modeled as functions of treatment, baseline ASPECTS, occlusion location, age, sex, baseline 
NIHSS, alteplase*thromb_app, study site     
 
Stroke volume 
continuous 
ITT 
Stroke volume (or cubic root transformation of stroke volume) modeled as a function of treatment, 
baseline ASPECTS, occlusion location, age, sex, baseline  NIHSS, alteplase*thromb_app, study site 
 
BNT15 
0-15 
ITT  
BNT15 Score modeled as a function of treatment, baseline ASPECTS, occlusion location, age, sex,  
baseline NIHSS, alteplase*thromb_app, study site     
 
SNAP 
0-100 
ITT 
Total SNAP Score modeled as a function of treatment, baseline ASPECTS, occlusion location, age, sex, 
baseline NIHSS, alteplase*thromb_app, study site     
 
MoCA 
Binary (<26 vs. 
≥26) 
ITT 
logit(binary MoCA) modeled as a function of treatment, baseline ASPECTS, occlusion location, age, 
sex, baseline NIHSS, alteplase*thromb_app, study site     
 
Day-30 mRS 
Binary 
(≤2 vs. >2) 
ITT 
logit(binary mRS) modeled as a function of treatment, baseline  ASPECTS, occlusion location, age, sex, 
baseline  NIHSS, alteplase*thromb_app, study site 
Exploratory 
Day-90 mRS 
Binary 
(≤2 vs. >2) 
ITT  
Separate logistic regression models in which the logit(binary mRS)is  modeled as a function of treatment 
only, by each of the subgroups to be considered in the Subgroup forest plots 
 
Day-90 mRS 
Binary 
(≤2 vs. >2) 
ITT 
logit(binary mRS) modeled as a function of treatment, baseline ASPECTS, occlusion location, age, sex, 
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Endpoint 
Type 
Endpoint 
Scale 
Population 
Statistical  Model 
 
All secondary 
endpoints 
As listed above 
ITT 
Modeled as described above as a function of treatment, baseline ASPECTS, occlusion location, age, sex, 
baseline NIHSS, alteplase*thromb_app, study site, period, and treatment by period interaction 
 
Day-90 mRS 
Binary 
(≤2 vs. >2) 
ITT  
logit(binary mRS) modeled as a function of treatment, baseline ASPECTS, occlusion location, age, sex, 
baseline  NIHSS, alteplase*thromb_app, study site, and time between tPA administration and infusion 
start 


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8.0 
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.  
8.1 
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 NA-1 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. 
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, Probably, Possibly, Unrelated). 
The following summaries (tables) of AEs and TEAEs will be provided by number 
(percentage) of subjects for each treatment group: 
• All TEAEs by MedDRA preferred term  


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• All TEAEs by MedDRA SOC and by preferred term  
• TEAEs (with a start date 0-30 days) by MedDRA SOC and by 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 NA-1 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, Probably, 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 
• TEAEs (onset 0-120 minutes post end of study drug infusion and of special interest 
as defined in Appendix 1) 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 
− 
All AEs related to study drug by MedDRA SOC and by preferred term 
− 
All deaths by treatment group 
8.2 
Vital Signs 
Vital signs will be taken in the supine position at Baseline (pre-dose), at the completion 
of drug infusion, and at 24 Hours, 48 Hours and Day 5/discharge. Vital signs including 
temperature, systolic and diastolic blood pressure, heart rate, and weight will be 


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reported by assessment time. Absolute values and changes for vital signs from pre-dose 
to Day 5 or discharge will be documented. The maximum deviation of BP from 
Baseline between drug and placebo control groups (systolic and diastolic) to 24 Hours 
will each be analyzed using ANCOVA, including factors for treatment group, the use 
of general anesthesia and treatment with intravenous alteplase, three factors that may 
affect blood pressure. Results will be tabulated and listed by treatment group and 
timepoint. 
8.3 
Laboratory and 12-Lead Electrocardiogram Results 
CBC, electrolytes, INR, aPTT, serum creatinine and serum glucose will be reported at 
24 ± 12 hours. A 12-lead ECG will be performed at Baseline or, if the treating physician 
deems that an ECG will impede the subject’s access to care, within 6 hours of 
randomization, and at 24 ± 12 hours. 
Absolute values for laboratory results and generalized 12-lead ECG results (i.e., 
normal, sinus bradycardia, etc.) will be summarized descriptively. Inferential statistics 
(ie, p-values or CI) will not be provided for these data.  
8.4 
Prior and Concomitant Medications 
Prior medications are defined as those taken within three days of treatment initiation. 
Concomitant medications (conmeds) will be collected from the time of randomization 
to the Day 30 Visit/contact. Prior and concomitant medications will be listed verbatim 
within treatment group. 
8.5 
Independent Data Monitoring Committee 
An Independent Data Monitoring Committee (IDMC) will perform periodic safety 
reviews of the clinical data. The reviews will occur after 100, 300, and 600 subjects 
have reached their 90-day study visit.  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, 
severity, and relatedness to the study medication and discontinuations due to AEs. 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) 


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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.  See the IDMC Charter (separate document) for additional details. 
The unblinded Independent Statistical Group (ISG) will be sequestered from the Project 
Team, steering committee and investigators. The ISG 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. A list of 
planned tables listings and figures to be included in the safety and efficacy reports are 
provided in Appendix A. Additional details of the interim analysis are provided in 
Section 3.0 of this document.  
The Statistical Group is responsible to: 
• 
Prepare Tables, Figures and Listings for the IDMC to review 
• 
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 to the IDMC 
The IDMC Project Administrator, also a member of the unblinded Statistical Group, 
will handle most communication between the IDMC and the Project Team, including 
the forwarding of the unblinded reports to the IDMC members and preparation of the 
Open and Closed Session meeting minutes. The IDMC Independent Reporting 
Statistician, also a member of the Statistical Group, also attends the Open and Closed 
Sessions of the IDMC meetings and answers any questions from the IDMC regarding 
the reports. 


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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. 
 
 


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9.0 
REFERENCES 
1. 
Aarts M, Liu Y, Liu L, Besshoh S, Arundine M, Gurd JW, et al. Treatment of 
ischemic brain damage by perturbing NMDA receptor- PSD-95 protein 
interactions. Science 2002;298(5594):846-850. 
2. 
Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et al. 
Randomized assessment of rapid endovascular treatment of ischemic stroke. 
N Engl J Med 2015;372(11):1019-1030. 
3. 
Tymianski M. Combining Neuroprotection With Endovascular Treatment of 
Acute Stroke: Is There Hope? Stroke 2017;48(6):1700-1705. 
4. 
Sun HS, Doucette TA, Liu Y, Fang Y, Teves L, Aarts M, et al. Effectiveness of 
PSD95 inhibitors in permanent and transient focal ischemia in the rat. Stroke 
2008;39(9):2544-2553. 
5. 
Cook DJ, Teves L, Tymianski M. Treatment of stroke with a PSD-95 inhibitor 
in the gyrencephalic primate brain. Nature 2012;483(7388):213-217. 
6. 
Hill MD, Martin RH, Mikulis D, Wong JH, Silver FL, Terbrugge KG, et al. 
Safety and efficacy of NA-1 in patients with iatrogenic stroke after 
endovascular aneurysm repair (ENACT): a phase 2, randomised, double-blind, 
placebo-controlled trial. Lancet Neurol 2012;11(11):942-950. 
7. 
Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-
retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl 
J Med 2015;372(24):2285-2295. 
8. 
Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. 
Endovascular therapy for ischemic stroke with perfusion-imaging selection. 
N Engl J Med 2015;372(11):1009-1018. 
9. 
Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo 
AJ, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. 
N Engl J Med 2015;372(1):11-20. 


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10. 
Zhao W, Hill MD, Palesch Y. Minimal sufficient balance-a new strategy to 
balance baseline covariates and preserve randomness of treatment allocation. 
Stat Methods Med Res 2015;24(6):989-1002. 
11. 
Lan KKG. Design and analysis of group sequential tests based on type-1 error 
spending rate function. Biometrika 1987;74:149-154. 
12. 
O'Brien PC, Fleming TR. A multiple testing procedure for clinical trials. 
Biometrics 1979;35:549-556. 
13. 
Agresti A. An Introduction to Categorical Data Analysis. 2nd Ed. edition. 2007, 
Hoboken, NJ: J. Wiley and Sons. 
14. 
Nunn A, Bath PM, Gray LJ. Analysis of the Modified Rankin Scale in 
Randomised Controlled Trials of Acute Ischaemic Stroke: A Systematic 
Review. Stroke Research and Treatment 2016:1-7. 
15. 
Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin 
I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for 
mild cognitive impairment. J Am Geriatr Soc 2005;53(4):695-699. 
16. 
Smith T, Gildeh N, Holmes C. The Montreal Cognitive Assessment: validity 
and utility in a memory clinic setting. Can J Psychiatry 2007;52(5):329-332. 
 
 


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Appendix 1:  Listing of AEs of Special Interest 
Table A-1: AEs Related to Angioedema (by PT) 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 PT) 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 PT) 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