Ultrasound Enhanced Thrombolytic Therapy of Middle Cerebral Artery Occlusion

Condition(s) targeted: Intracranial Embolism; Thrombosis

Intervention: transcranial ultrasound in patients treated with iv t-PA (Procedure)

Phase: Phase 3

Status: Recruiting

Sponsored by: University of Zurich

Official(s) and/or principal investigator(s):
Ralf W Baumgartner, MD, Study Chair, Affiliation: University Hospital of Zurich, Department of Neurology, Zurich, Switzerland

Overall contact:
Ralf W Baumgartner, MD, Phone: +41 1 255 56 86, Email: ralf.baumgartner@usz.ch

The purpose of the present, randomized, controlled multicenter phase III trial is to investigate the safety and efficacy of continuous 1-hour insonation of occluded middle cerebral artery with 2 MHz TCCS in stroke patients treated with intravenous tissue plasminogen activator (t-PA) within 3 hours after symptom onset.

Official title: Transcranial Ultrasound Enhanced Thrombolysis (TRUST)

Study design: Treatment, Randomized, Open Label, Active Control, Parallel Assignment, Safety/Efficacy Study

Primary outcome:

Symptomatic intracranial hemorrhage (safety)

Functional outcome (efficacy)

Secondary outcome:

Asymptomatic intracranial hemorrhage 24-48 hours after t-PA infusion

Early clinical recovery by 10 or more NIHSS points or dramatic recovery (total NIHSS 3 or less)at 24-48 hours after t-PA infusion

Mean mRS score at 90 days after t-PA infusion

Death occurring during study period

Recanalization at 24-48 hours after t-PA infusion

Detailed description: Thrombolysis with intravenous(iv) tissue plasminogen activator (t-PA) is the only effective and approved therapy for acute ischemic stroke. The most frequent cause of ischemic stroke is thrombosis of the middle cerebral artery (MCA). Preliminary in vitro, animal and human studies suggest that ultrasound accelerates thrombolysis induced by t-PA, and recanalization of acute MCA occlusion due to thrombolysis is an independent predictor of good clinical outcome. Thus, insonation of an occluded MCA through the temporal bone in stroke patients who are treated with iv t-PA might enhance recanalization and improve clinical outcome. The present prospective, randomized, controlled multicenter pilot study will investigate the safety and efficacy of continuous 1-hour insonation of the occluded MCA with 2 MHz transcranial color duplex sonography in patients with ischemic stroke treated with iv t-PA within 3 hours after symptom onset. It is planned to randomize 400 patients in 6 Swiss centers during an enrolment period of 33 months with an individual follow up of 3 months. The study endpoints include safety and efficacy assessments. The primary safety endpoint is to determine the rate of symptomatic intracranial hemorrhage (ICH) in both treatment groups. The primary efficacy endpoint is to determine whether a good functional outcome (modified Rankin scale, mRs, score of 0-2) differs between both treatment groups. Secondary endpoints include (1) asymptomatic ICH occuring during or within the first 24-48 hours after t-PA infusion, (2) early clinical recovery by 10 or more National Institute of Health Stroke Scale (NIHSS) points or dramatic recovery (total NIHSS score of 3 or less) at 24-48 hours after t-PA infusion, (3) mean mRS score at 90 days after t-PA infusion, (4) death occuring during the study period, and (5) recanalization at 24-48 hours after t-PA infusion.

Minimum age: N/A. Maximum age: N/A. Gender(s): Both.

Criteria:

Inclusion Criteria:

- acute ischemic stroke in the MCA territory according to clinical and cranial computed

tomography (CT) or cranial MR imaging (MRI) findings

- patient undergoing iv thrombolysis with t-PA within 3 hours after stroke onset

- Occlusion of sphenoidal (M1) or insular (M2) segment of the MCA at CT (CTA), MR (MRA)

or catheter (CA) angiography

- appropriate temporal bony window without echocontrast agents for insonation with TCCS

- full functional independence prior to present stroke (mRS 0-1), use of a cane for

walking due to comorbid condition is acceptable

- written informed consent, signed and dated by the subject (or subject's authorized

representative, if allowed by local laws) and by the person obtaining the consent, indicating agreement to comply with all protocol-specific procedures

Exclusion Criteria:

- unconsciousness (more than 2 points on item 1a on NIHSS)

- history of intracranial hemorrhage, arteriovenous malformation or aneurysm

- severe cranio-cerebral trauma within the last 3 months

- symptoms of subarachnoidal hemorrhage

- time of symptom onset unclear

- large surgical intervention or trauma within the last 10 days

- expected survival below 90 days after iv t-PA treatment

- severe hepatic disease, esophageal varices, acute pancreatitis

- septic embolism, endocarditis, pericarditis after myocardial infarction

- pregnancy or childbirth within the last 30 days or nursing mothers

- history of hemorrhagic diathesis or coagulopathy

- untreatable increase of arterial blood pressure (>185mmHg systolic, >110mmHg

diastolic)

- intracranial hemorrhage, arteriovenous malformations or aneurysm at brain imaging

- thrombocytes <100'000 per microliter

- international normalized ratio (INR)>1. 7 or partial thromboplastin time (PTT)

prolongated

- serum glucose <2. 7mmol/l or >22. 2mmol/l

- severe renal insufficiency or other contraindications against CT-contrast agents

Ralf W Baumgartner, MD, Phone: +41 1 255 56 86, Email: ralf.baumgartner@usz.ch

University Hospital of Zurich, Department of Neurology, Zurich 8091, Switzerland; Recruiting
Ralf W Baumgartner, MD, Phone: +41 1 255 56 86, Email: ralf.baumgartner@usz.ch
Dimitrios Georgiadis, MD, Email: dimitrios.georgiadis@usz.ch
Ralf W Baumgartner, MD, Principal Investigator
Dimitrios Georgiadis, MD, Principal Investigator
Hakan Sarikaya, MD, Sub-Investigator

Kantonsspital Aarau, Department of Neurology, Aarau, Switzerland; Recruiting
Hansjörg Hungerbühler, MD, Phone: +41 62 838 66 75, Email: hansjoerg.hungerbuehler@ksa.ch
Hansjörg Hungerbühler, MD, Principal Investigator

University Hospital of Basel, Department of Neurology, Basel, Switzerland; Recruiting
Stefan Engelter, MD, Phone: +41 61 265 25 25, Email: sengelter@uhbs.ch
Philippe Lyrer, MD, Principal Investigator
Stefan Engelter, MD, Principal Investigator

University hospital of Bern, Department of Neurology, Bern, Switzerland; Recruiting
Marcel Arnold, MD, Phone: +41 31 632 33 32, Email: marcel.arnold@insel.ch
H.-P. Mattle, MD, Principal Investigator
Marcel Arnold, MD, Principal Investigator

University Hospital of Geneva, Department of Neurology, Geneva, Switzerland; Recruiting
Roman Sztajzel, MD, Phone: +41 22 372 83 10, Email: Roman.Sztajzel@hcuge.ch
Roman Sztajzel, MD, Principal Investigator

University Hospital of Lausanne, Department of Neurology, Lausanne, Switzerland; Recruiting
Patrik Michel, MD, Phone: +41 21 314 11 85, Email: patrik.michel@chuv.hospvd.ch
Patrik Michel, MD, Principal Investigator

Starting date: June 2006
Ending date: June 2009
Last updated: April 25, 2007