Brain Ischemia, Endovascular Procedure, Subarachnoid Hemorrhage, Aneurysmal
Conditions
Keywords
Aneurysmal subarachnoid hemorrhage, platelet aggregation inhibitors, ticagrelor, thromboembolic events, delayed cerebral ischemia
Brief summary
Among aneurysmal subarachnoid hemorrhage (aSAH) survivors, ischemic injuries such as peri procedural thromboembolic events (TEE) and delayed cerebral ischemia (DCI) represent the most important disabling complications. However, preventive strategies are limited. Platelet activation mechanisms play a critical role in the pathophysiology of TEE and DCI. The results of several meta analyses suggested that use of antiplatelet drugs (APD) could reduce the risk of TTE/DCI. We aim to evaluate in patients with a low grade aSAH (WFNS 1 to 3) that occurred for less than 72 hours ago, the effect of 14 days course of ticagrelor vs placebo, initiated at the beginning of the endovascular treatment of the aneurysm, on the ischemic complications (peri-procedural symptomatic and asymptomatic TEE and/or neurological worsening due to DCI) occurring within 14 days of the endovascular treatment of the aneurysm.
Detailed description
After aSAH, ischemic complications such as peri-procedural TEE and DCI prevalence are as high as 15 and 30% of the patients respectively. They are the main causes of disability in patients who survive the initial bleeding. The diagnoses of TEE and DCI may be difficult in patients experiencing high grade aSAH contrariwise to low grade where clinical exam and reliable imaging of brain ischemia could be performed. In addition, TEE/DCI dramatically impact the prognosis of these patients who had no/minor initial deficit. Platelet activation and thrombo-inflammatory mechanisms play a critical role in the pathophysiology of TEE and DCI through multiple pathways. Several APD have been evaluated to mitigate TEE/DCI risk with heterogeneous results. A recent metanalysis suggested that APD could reduce TEE incidence by 13 %. Interestingly patients receiving mono or dual APD just before aneurysmal repair did not experience an increased hemorrhagic risk. Regarding DCI, aspirin failed to demonstrate any benefit in an European randomized controlled trial while 3 recent meta-analyses suggested that APD use may be associated with a relative risk reduction of 40-50%. Hence, in the absence of positive trials no APD use is not recommended for the management of aSAH. Compared to previous APD used in aSAH, Ticagrelor, a reversible P2Y12 receptor inhibitor, has a promising profile to control TEE/ DCI: stronger and shorter antiplatelet action as well as vasodilatory and anti-inflammatory effects. Two hundred and seventy-four patients will be randomized 1:1 in Ticagrelor or placebo group within 72hrs of aneurysm rupture in a multicentre prospective double-blind, parallel group study. Ticagrelor/placebo will be administered orally just before the endovascular treatment of the aneurysm with a loading dose of 180 mg, followed by 90 mg twice a day during 2 weeks. We will assess a composite primary end point based on the occurrence of ischemic complications: peri-procedural asymptomatic and symptomatic TEE and/or neurological deterioration due to DCI. During the first 24H, TEE is defined by clotting or arterial occlusion on angiography during endovascular procedure and/or 24hrs-MRI infarctions and/or neurological deterioration defined by the worsening ≥2pts from baseline on NIHSS performed immediately after the intervention, then every 6 hours. From day 2 to 15, multi daily clinical monitoring using NIHSS will be performed to assess the occurrence of neurological deterioration due to DCI, defined as worsening ≥2pts on NIHSS, lasting for at least 2hrs. A brain imaging- MRI recommended- is needed in the case of neurological deterioration to confirm its ischemic mechanism. Rescue therapies for DCI will be feasible according to a decisional algorithm. Systematic MRI will be performed within the 24hrs of the endovascular procedure and 15 days after randomization in order to detect, confirm and quantify cerebral infarcts. At 3 months, visit will include functional outcome with the mRS and the GOSE, cognitive functions with the Montreal Cognitive Assessment (MoCA) and quality of life using EQ-5D. Any hemorrhagic complication related to SAH (rebleeding during the procedure, hydrocephalus requiring ventricular drain, intracerebral hemorrhage) other major bleedings and side effects of the treatment such as dyspnea will be carefully monitored and reported.
Interventions
DRUGExperimental group: ticagrelor
Patients with a low grade aSAH receiving ticagrelor. Ticagrelor will be administered orally just before the endovascular treatment of the ruptured aneurysm with a loading dose of 180mg, followed by 90 mg twice a day during 2 weeks.
DRUGControl group: placebo
Patients with a low grade aSAH receiving placebo. Placebo will consist of tablets identical to ticagrelor ones, administered orally with a loading dose of 2 tablets, followed by 1 tablet twice a day during 2 weeks
Sponsors
University Hospital, Toulouse
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Investigator)
Eligibility
Sex/Gender
ALL
Age
18 Years to 80 Years
Healthy volunteers
No
Inclusion criteria
* Age 18 - 80 years old * Low grade aneurysmal subarachnoid hemorrhage defined by a WFNS 1-3 * Aneurysmal treatment planned to be completed within 72 h after rupture * Sacciform aneurysm diameter ≥ 4 mm * Ruptured aneurysm treatable by endovascular, endo-saccular technic (stent and flow diverters are not allowed). If the aneurysm responsible of the SAH is difficult to identify, several aneurysms that may be related to the SAH can be treated during the procedure. * Affiliated person or beneficiary of a social security scheme. * Free, informed and written consent signed by the participant or truthworthy/proxy representative and the investigator (at the latest on the day of inclusion and before any examination required by the research).
Exclusion criteria
* Poor grade aSAH defined as WFNS 4 and 5 * Fusiform, dissecting, thrombosed aneurysms and aneurysm associated with brain arteriovenous malformation * Associated unruptured aneurysm requiring treatment within 3 months * History of intracranial hemorrhage within the past 6 months * Intraparenchymal hematoma associated with SAH -Ongoing antiplatelet drug * Acute symptomatic hydrocephalus or ventricular derivation * Intra-ventricular hemorrhage on admission CT scan, filling \>50% of both lateral ventricles and 3rd and 4th ventricles * Pre aSAH mRS ≥ * Active pathological bleeding and notably recent extra cranial hemorrhage (within previous 30 days), gastrointestinal hemorrhage within the past 6 months, or major surgery within 30 days * Other contra-indications to Ticagrelor: hypersensitivity to the active substance or to any of the excipients, * Severe hepatic or kidney failure, * Concomitant administration of strong CYP3A4 inhibitors(for ex ketoconazole, clarithromycine, nefazodone, ritonavir and atazanavir) drugs that interfered with P-glycoprotein transporter * Respiratory failure, asthma , obstructive broncho-pneumopathy * Pregnant and breastfeeding women * Patients under guardianship or other legal protection, deprived of their liberty by judicial or administrative decision
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Effect of tricagrelor on the ischemic complications: peri-procedural thromboembolic events | 24 hours | It will be assessed by the occurence of symptomatic and asymptomatic peri-procedural thromboembolic events within the first 24 hours after the procedure. These events can be : * angiographic : any event with clotting near the neck of the aneurysm or in distal branches and parent vessel occlusion in any vascular territory during procedure, and/or * Clinical: worsening neurological deficit ≥2 points on NHISS from baseline after the procedure not attribuable to other causes, and/or * Imaging: acute infarctus on 24h MRI The NIHSS (National Institutes of Health Stroke Scale) is a clinical scale used primarily to assess the severity of a stroke. It consists of 15 items which assigns a score ranging from 0 to 42 (0 corresponds to no measurable deficit and 42 to the maximum neurological deficit). |
| Effect of tricagrelor on the ischemic complications: neurological deterioration | 14 days | It will be assessed by the occurence of neurological deterioration due to delayed cerebral ischemia DCI within 14 days of the endovascular treatment. It will be caracterized by a worsening deficit (≥2 points on NIHSS scale from the previous evaluation), lasting at least 2 hours, not attributed to other causes. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Peri-procedural asymptomatic and symptomatic TEE: angiographic | 24 hours | It will be assessed by the occurence of one peri-procedural angiographic TEE that is, any event with clotting near the neck of the aneurysm or in distal branches and parent vessel occlusion in any vascular territory during procedure within 24 hours of aneurysmal treatment. |
| Peri-procedural asymptomatic and symptomatic TEE: clinical | 24 hours | It will be assessed by the occurence of at least one peri-procedural clinical TEE that is, symptomatic ischemic lesions defined by a worsening ≥2pts on NIHSS from baseline, not attributable to other causes within 24 hours of aneurysmal treatment. |
| Peri-procedural asymptomatic and symptomatic TEE: ischemic lesion | 24 hours | It will be assessed by the occurence of at least one severe symptomatic ischemic lesion defined by worsening \>4 points on NIHSS from baseline within 24 hours after the aneurysmal treatment. |
| Peri-procedural asymptomatic and symptomatic TEE: imaging | 24 hours | It will be assessed by the occurence of at least one peri-procedural TEE that is, acute infarctus on MRI performed within 24 hours after endovascular treatment. |
| Neurological deterioration and asymptomatic lesions on MRI due to DCI | 15 days | It will be assessed by the occurence of at least one neurological deterioration due to DCI (worsening ≥2pts on NIHSS compared with previous evaluation), lasting at least 2 hrs, not attributed to other causes after a brain imaging at day 15. |
| Neurological deterioration and asymptomatic lesions on MRI due to DCI: severe neurological deterioration | 15 days | It will be assessed by the occurence of at least one severe neurological deterioration due to DCI defined by worsening \>4 points on NIHSS compared to previous evaluation, at day 15. |
| Neurological deterioration and asymptomatic lesions on MRI due to DCI: asymptomatic MRI lesions | 15 days | It will be assessed by the occurence of new infarctus on MRI at day 15. |
| Neurological deterioration and asymptomatic lesions on MRI due to DCI: ischemic event | 15 days | It will be assessed by the occurence of at least one ischemic event (clinical/MRI) related to DCI, at day 15. |
| Total incidence of ischemic events per patient | 15 days | It will be assessed by the combined incidence of all ischemic events: sum of both type of ischemic events (related to TEE and/or DCI) at day 15. |
| Need for rescue therapy during embolization and/or DCI | 14 days | It will be assessed by the rate of rescue therapy for angiography defined by any mechanical maneuvers (catheter aspiration, stentrievers use or any pharmacological intra-arterial or intravenous therapies) within 14 days of treatment. |
| Aneurysm occlusion | 3 months | It will be assessed by the quality of the aneurysm occlusion evaluated at procedure completion, 24 hours and 3 months MRI/MRA based on the Raymond-Roy classification. The Raymond-Roy classification is an angiographic classification used to describe the degree of aneurysm occlusion: * Class 1: complete occlusion * Class 2: residual neck * Class 3: residual aneurysm. |
| Clinical outcome at 3 months: good functionnal outcome (disability and functional dependence) | 3 months | It will be assessed by the Modified Rankin Scale (mRS) with a score that must be below 3. It is a clinical scale that measures a patient's degree of disability and functional dependence on a scale from 0 to 6 (the higher the score, the greater the disability and dependence). It will be performed at visit 16 (3 months). |
| Clinical outcome at 3 months: good functional outcome (disability and recovery) | 3 months | It will be assessed by the GOSE (Glasgow Outcome Scale-Extended) with a score that must be above 5. It is a scale used to assess the level of recovery and disability following a brain injury; it has 8 levels, ranging from 1 (death) to 8 (good recovery). It will be performed at visit 16 (3 months). |
| Clinical outcome at 3 months: quality of life | 3 months | It will be assessed by the EQ-5D questionnaire at visit 16 (3 months). It is a health-related quality of life questionnaire that assesses five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each item is rated on a 5-point scale, resulting in a total score ranging from 1 to 100, where 0 represents the worst possible health status and 100 represents the best. |
| Clinical outcome at 3 months: cognitive deterioration | 3 months | The rate of cognitive deterioration will be defined by a MoCA score below or equal to 25, performed at visit 16 (3 months). The MoCA (Montreal Cognitive Assessment) is a screening test for cognitive disorders that yields a score ranging from 0 to 30 (where 0 indicates severely impaired cognitive function and 30 indicates optimal performance). |
| Clinical outcome at 3 months: deaths | 3 months | It will be assessed by the number of deaths occuring during the totality of the research (3 months). |
| Occurence of adverse events | 3 months | All adverse events during the totality of the research (3 months) will be collected. |
Countries
France
Contacts
CONTACTLionel Calvière, MD
PRINCIPAL_INVESTIGATORLionel Calvière
Toulouse Hospital University
Outcome results
None listed