Ischemic Stroke, Tandem Occlusion
Conditions
Keywords
Ischaemic stroke, Stenting, Endovascular thrombectomy, tandem occlusion
Brief summary
Co-STAR is a multicenter, prospective, open-label, Bayesian Optimal Phase 2 (BOP2) trial that aims to assess the safety and efficacy of adjunctive intravenous TBO-309 in Acute Ischaemic Stroke (AIS) patients with tandem occlusion receiving intra-cranial endovascular thrombectomy (EVT) and acute extracranial carotid artery stenting. Co-STARS study will test the hypothesis that patients with tandem occlusion treated with EVT and acute stenting in conjunction with TBO-309 will: * have persistent stent patency without requiring rescue therapy with GPIIb/IIIa inhibitors and * not experience high rates of symptomatic intra-cranial haemorrhage (sICH). Patients with tandem occlusion undergoing EVT and acute stenting will receive intravenous TBO-309 bolus and infusion. TBO-309 is a potent, selective and ATP competitive PI3K\[beta\] inhibitor which reduces platelet activation adhesion/aggregation particularly under conditions of disturbed blood flow and promotes platelet disaggregation. By targeting PI3K\[beta\], TBO-309 specifically inhibits thrombosis whilst minimizing the impact on normal hemostasis.
Detailed description
Stroke due to large vessel occlusion (LVO) typically causes large infarcts and results in severe disability and a high case fatality rate. Treating LVO by thrombectomy poses technical challenges, especially when the lesion involves not only the extracranial (cervical) part of the internal carotid artery but also its concomitant intracranial distal segment or the ipsilateral middle cerebral artery (tandem occlusion). For patients with tandem occlusion, stenting of the internal carotid is considered acceptable, but it requires the use of antiplatelet therapy to avoid stent thrombosis, often necessitating rescue therapy with GPIIb/IIIa inhibitors. This can lead to an increased risk of hemorrhage especially when potent antiplatelet agents such as GPIIb/IIIa inhibitors are used. The novel investigational agent TBO-309 is a potent, selective and ATP competitive PI3K\[beta\] inhibitor which reduces platelet activation adhesion/aggregation particularly under conditions of disturbed blood flow and promotes platelet disaggregation. By targeting PI3K\[beta\], TBO-309 specifically inhibits thrombosis whilst minimizing the impact on normal hemostasis. This study aims to assess the safety and efficacy of adjunctive TBO-309 in acute ischaemic stroke with tandem occlusion eligible to undergo intra-cranial EVT and acute extracranial carotid artery stenting. The primary endpoint of this trial is a composite outcome of efficacy and safety, defined by: 1. Avoidance of intra-procedural GPIIb/IIIa inhibitor rescue therapy due to stent thrombosis, combined with persistent stent patency seen on angiographic imaging at 24-36 hours, and 2. no sICH. This trial will use Bayesian Optimal Phase 2 (BOP2) trial design, and two intervention doses will be tested sequentially for TBO-309. TBO-309 at the dose of 60 mg will be tested first. Then either a higher dose of 120 mg or a lower dose of 30 mg will be tested based on the results of the 60 mg dose.
Interventions
DRUGTBO-309: 60 mg
TBO-309 is a potent, selective and ATP competitive PI3Kβ inhibitor which blocks platelet activation adhesion/aggregation and promotes platelet disaggregation. By targeting PI3Kβ, TBO-309 specifically inhibits thrombosis whilst minimizing the impact on normal haemostasis.
DRUGTBO-309: 120 mg
TBO-309 is a potent, selective and ATP competitive PI3Kβ inhibitor which blocks platelet activation adhesion/aggregation and promotes platelet disaggregation. By targeting PI3Kβ, TBO-309 specifically inhibits thrombosis whilst minimizing the impact on normal haemostasis.
DRUGTBO-309: 30 mg
TBO-309 is a potent, selective and ATP competitive PI3Kβ inhibitor which blocks platelet activation adhesion/aggregation and promotes platelet disaggregation. By targeting PI3Kβ, TBO-309 specifically inhibits thrombosis whilst minimizing the impact on normal haemostasis.
Sponsors
ThromBio Pty. Ltd.
Study design
Allocation
NON_RANDOMIZED
Intervention model
SEQUENTIAL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Masking description
Masking Description: Independent imaging assessors will review and adjudicate blinded study data to ensure the primary endpoint meets consistent pre-determined diagnostic criteria. Imaging assessors will be qualified physicians who are independent of the study and not involved in study management.
Intervention model description
Multicenter, prospective, open-label, Bayesian Optimal Phase 2 (BOP2) trial. Two intervention doses will be tested sequentially for TBO-309, with 60mg tested first. Then either a higher (120mg) or lower (30mg) dose will be tested, based on results of the 60 mg dose. The maximum number of subjects is estimated to be 78 in this two-dose BOP2 design study.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Patient aged 18 years or more 2. Patient has an AIS due to tandem occlusion, including large vessel occlusion (LVO) within the intra-cranial anterior circulation and presumed atherosclerotic occlusion of the cervical internal carotid artery origin 3. CT perfusion indicates the presence of salvageable brain tissue, defined as ischaemic core \<70mL with a mismatch ratio \>1.8 and absolute mismatch \>15mL. 4. Patient has at least a mild grade of neurological impairment (NIHSS \>4) 5. Patient has an estimated pre-stroke mRS of less than 4
Exclusion criteria
1. Patient is considered unlikely to benefit from study intervention defined by one of the following: 1. Advanced dementia 2. Severe pre-stroke disability (mRS score 4-5) 3. Glasgow Coma Score (GCS) 3 to 5 4. Evidence of a large well-defined ischaemic lesion measuring more than one third of the middle cerebral artery (MCA) territory 2. Uncontrolled hypertension (SBP \>180 or DBP \>110, refractory to medical therapy) 3. Intracranial haemorrhage within the last 90 days 4. Myocardial infarction or stroke within the last 30 days 5. Patient has an underlying disease process with a life expectancy of \<90 days 6. Known treatment with anticoagulants 7. Known severe liver disease 8. Known bleeding disorder 9. Cardiopulmonary resuscitation or arterial puncture at non-compressible site or lumbar puncture within 7 days 10. Another medical illness or social circumstance that may interfere with outcome assessments and follow-up 11. Known or suspected pregnancy 12. Patients currently participating in another interventional clinical trial 13. Informed consent unable to be obtained from the patient or their Person Responsible/Medical Treatment Decision Maker prior to study interventions
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of patients achieving a composite outcome of efficacy and safety | 24-36 hours | The primary endpoint is a composite outcome of efficacy and safety, defined by the proportion of patients who 1) avoid intra-procedural GPIIb/IIIa inhibitor rescue therapy due to stent thrombosis, combined with persistent stent patency seen on angiographic imaging at 24-36 hours, and 2) have no sICH. sICH is defined as parenchymal haemorrhage type 2 (PH2) on imaging. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of patients achieving reperfusion. | 24 hours | The proportion of patients achieving reperfusion, where reperfusion is defined by the expanded Thrombolysis in Cerebral Infarction scale (eTICI) 2b50 or better (i.e. 50% to 100%) |
| Infarct volume 24-36 hours post study drug commencement | 24-36 hours | — |
| Proportion of all patients with any ICH within 24-36 hours post study drug commencement | 24-36 hours | All ICH as demonstrated on brain imaging at 24-36 hours, where ICH will be classified according to The Heidelberg Bleeding Classification. |
| National Institutes of Health Stroke Scale (NIHSS) at 24 hours, and 7 days/at hospital Discharge | 24 hours and 7 days | The National Institutes of Health Stroke Scale (NIHSS) is a 15-item neurological examination stroke scale. Scores range from 0 to 42, with higher scores indicating greater severity. |
| Modified Rankin Scale (mRS) score at discharge and 90 days | 90 days | The Modified Rankin Scale (mRS) is a scale from 0 to 6, with higher scores indicating greater disability (5), and death (6). |
| Proportion of patients with all-cause mortality at 90 days. | 90 days | — |
| Proportion of patients experiencing any bleeding within 24-36 hours of study drug commencement. | 24-36 hours | The proportion of patients experiencing any bleeding within 24-36 hours of study drug commencement. Bleeding will be determined using a modified WHO scale with grades 1 and 2 classified as minor bleeding, and grades 3 and 4 as major bleeding. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Proportion of patients with sICH | 24-36 hours | The safety outcome is symptomatic intra-cranial haemorrhage (sICH) within 24-36 hours of study drug commencement. sICH is defined as parenchymal haemorrhage type 2 (PH2) on imaging within 24-36 hours after treatment, associated with a ≥ four-point deterioration on the National Institutes of Health Stroke Scale (NIHSS) from baseline or from the lowest score to 24-36 hours or leading to death. |
Countries
Australia
Contacts
Primary ContactFerdinand Miteff - Interventional Neurologist, RACP, CCINR
Backup ContactCandice Delcourt, MD, PhD and FRACP
Outcome results
None listed