Secondary Prevention of Small Subcortical Strokes Trial

• Status: Completed
• Trial end date: 2012-04-01
• Target enrollment: 0
• Participant gender: All

Summary

The goal of this study is to learn if combination antiplatelet therapy (aspirin and clopidogrel) is more effective than aspirin alone for the prevention of recurrent stroke and cognitive decline, and if intensive blood pressure control is associated with fewer recurrent strokes and cognitive decline.

On July 21, 2011 the DSMB recommended terminating the anti platelet arm of the study due to an imbalance of overall and major non-CNS hemorrhagic SAE's and total deaths in the investigational anti platelet combination of aspirin + clopidogrel and an interim statistical analysis that demonstrated futility in the investigational anti platelet arm. It was recommended that patients be continued on standard care of aspirin mono therapy until their study close-out visit. Also, recommended the continuation and completion of the plood pressure arm following the protocol.

• Phase: Phase 3
• Accepts Healthy Volunteers?: No

Details

• Lead Sponsor: University of British Columbia
• Collaborator: National Institute of Neurological Disorders and Stroke (NINDS)
• Treatments: Aspirin; Clopidogrel; Ticlopidine

Criteria

INCLUSION:

Small subcortical ischemic stroke or subcortical TIA.

Inclusion criteria are based on TOAST criteria supplemented by required MRI data. All of the following criteria must be met:

• One of the lacunar stroke clinical syndromes (adapted from Fisher) lasting > 24 hrs within the past 6 months

• Absence of signs or symptoms of cortical dysfunction such as aphasia, apraxia, agnosia, agraphia, homonymous visual field defect, etc.

• No ipsilateral cervical carotid stenosis (≥50%) by a reliable imaging modality done in an approved laboratory since the qualifying small subcortical stroke (S3), if hemispheric.

• No major-risk cardioembolic sources requiring anticoagulation or other specific therapy. Minor-risk cardioembolic sources will be permitted if anticoagulation is not prescribed by the patient's primary care physician.

• Subcortical TIA with corresponding lesion on DWI.

• MRI evidence of S3: a. Presence of an S3 (1.5 and 2 cm in diameter corresponding to the qualifying event on DWI; when TIA, ADC image must confirm lesion or T2/FLAIR (hyperintense lesions) (required for all brainstem events) OR multiple S3s on FLAIR/TI(<1.5 cm in diameter) (hypointense lesions) b. Absence of cortical stroke and large subcortical stroke (recent or remote).

EXCLUSION:

To be eligible for entry into the study, the patient must not meet any of the criteria listed below:

• Disabling stroke (Modified Rankin Scale less than or equal to 4)

• Previous intracranial hemorrhage (excluding traumatic) or hemorrhagic stroke

• Age under 30 years

• High risk of bleeding (e.g. recurrent GI or GU bleeding, active peptic ulcer disease, etc)

• Anticipated requirement for long-term use of anticoagulants (e.g. recurrent DVT) or other antiplatelets

• Prior cortical stroke (diagnosed either clinically or by neuroimaging), or prior cortical or retinal TIA

• Prior ipsilateral carotid endarterectomy

• Impaired renal function: GFR <40

• Intolerance or contraindications to aspirin or clopidogrel (including thrombocytopenia, prolonged INR)

• A score < 24 (adjusted for age and education) on the Folstein Mini Mental Status Examination

• Medical contraindication to MRI

• Pregnancy or women of child-bearing potential who are not following an effective method of contraception

• Geographic or social factors making study participation impractical

• Unable or unwilling to provide informed consent

• Unlikely to be compliant with therapy/unwilling to return for frequent clinic visits

• Patients concurrently participating in another study with an investigational drug or device

• Other likely specific cause of stroke (e.g. dissection, vasculitis, prothrombotic diathesis, drug abuse)