SONOlysis in Prevention of Brain Infarctions dUring Carotid Stenting and caroTid EndaRterectomy (SONOBUSTER)

This study is currently recruiting participants. (see Contacts and Locations)
Verified April 2014 by University Hospital Ostrava
Sponsor:
Collaborator:
Palacky University
Information provided by (Responsible Party):
Vaclav Prochazka, MD, PhD. MSc, University Hospital Ostrava
ClinicalTrials.gov Identifier:
NCT01591005
First received: April 23, 2012
Last updated: April 9, 2014
Last verified: April 2014
  Purpose

The aim of the project is to demonstrate a fibrinolytic effect of sonothrombolysis (continual transcranial Doppler monitoring) using 2 MHz diagnostic probe on the reduction of risk of brain infarctions due to the activation of endogenous fibrinolytic system during carotid endarterectomy (CEA) and carotid stenting (CS). 240 patients indicated for CEA (120 patients) and CS (120 patients) will be enrolled into the study in order to demonstrate a twenty-percent risk reduction of number and volume of brain infarctions detected using MRI examination 24 hours after CEA or CS in 5% level of significance. Patients will be randomized - subgroup 1 will undergo a 60minute non-diagnostic TCD monitoring during CEA or CS, subgroup 2 will undergo interventions without TCD monitoring. The second aim is to compare number of brain infarctions detected using MRI between CEA and CS patients.

Confirmation of the investigators hypothesis that sonothrombolysis is able to activate endogenous fibrinolytic system during CEA or CS with consecutive reduction of the number and volume of brain infarcts, can lead to the increase of the safety of CEA and CS in patients with internal carotid artery stenosis. The investigators can presume that up to 50% of patients indicated for CEA or CS can be treated using these methods in the future.

In the Substudy "Risk of brain infarction after carotid endarterectomy and stenting" the the risk of asymptomatic and symptomatic brain infarctions, changes in cognitive functions, as well as morbidity and mortality at 30 days between patients with symptomatic and asymptomatic severe ICA stenoses undergoing elective CEA and CAS will be compared.

The sample size of the Substudy was based on an expected 80% difference of new ischemic lesions on DWI-MRI between CEA (estimated prevalence, 30%) and CAS (54%). Pre-study calculations showed that a minimum of 73 patients in each group was needed to reach a significant difference with an alpha value of 0.05 (two-tailed) and a beta value of 0.8 assuming that 15% of subjects would be lost to follow-up or refuse to participate in the study.


Condition Intervention Phase
Internal Carotid Artery Stenosis
Procedure: sonolysis
Procedure: endarterectomy
Procedure: carotid stenting
Phase 3

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Single Blind (Outcomes Assessor)
Primary Purpose: Prevention
Official Title: Risk Reduction of Symptomatic and Silent Brain Infarctions During Carotid Endarterectomy and Carotid Stenting Due to Ultrasound Activation of Endogenous Fibrinolytic System Using Transcranial Doppler Monitoring

Resource links provided by NLM:


Further study details as provided by University Hospital Ostrava:

Primary Outcome Measures:
  • New brain infarction detected using MRI [ Time Frame: 24 hours after intervention ] [ Designated as safety issue: Yes ]

    Reduction of number and volume of brain infarctions in sonolysis group detected using MRI examination 24 hours after CEA or CS.

    Substudy: The incidence of new ischemic lesions on brain DWI-MRI performed 24 hours after intervention in CEA and CAS groups.



Secondary Outcome Measures:
  • New brain infarctions detected using MRI in endarterectomy and stenting groups [ Time Frame: 24 hours after intervention ] [ Designated as safety issue: No ]

    The number and volume of brain infarctions and brain infarctions >0.5 cm3 detected using MRI examination 24 hours after intervention between endarterectomy and stenting using periprocedural sonolysis.

    Substudy: The number and volume of brain infarctions and brain infarctions >0.5 cm3 detected using MRI examination 24 hours after intervention between CEA and CS groups.


  • Cognitive decline [ Time Frame: 24 hours after intervention ] [ Designated as safety issue: No ]

    The reduction of cognitive decline after CEA and CS measured by ADAS, MMSE, Clock Drawing Test and Verbal Fluency Test using periprocedural sonolysis.

    Substudy: The reduction of cognitive decline after intervention measured by ADAS, MMSE, Clock Drawing Test and Verbal Fluency Test between CEA and CS groups.


  • Clinical manifested brain infarction [ Time Frame: 24 hours and 30 days after intervention ] [ Designated as safety issue: Yes ]

    The reduction of risk of stroke or TIA (at 24 hours and 30 days) due to the activation of endogenous fibrinolytic system during CEA and CS using periprocedural sonolysis.

    Substudy: The reduction of risk of stroke or TIA (at 24 hours and 30 days) due to the activation of endogenous fibrinolytic system between CEA and CS groups.


  • New ipsilateral brain infarctions detected using MRI in endarterectomy and stenting groups [ Time Frame: 24 hours after intervention ] [ Designated as safety issue: No ]

    The number and volume of ipsilateral brain infarctions detected using MRI examination 24 hours after intervention between endarterectomy and stenting using periprocedural sonolysis.

    Substudy: The number and volume of ipsilateral brain infarctions detected using MRI examination 24 hours after intervention between CEA and CS groups.


  • Clinical vascular event or death [ Time Frame: 30 days after intervention ] [ Designated as safety issue: Yes ]

    The reduction of risk of the occurrence of death, any stroke, or myocardial infarction within 30 days (myocardial infarction was defined as a post-interventional cardiac troponin T level increase >2-fold the upper limit of normal in addition to either chest pain or symptoms consistent with ischemia or electrocardiographic evidence of ischemia) after CEA and CS using periprocedural sonolysis.

    Substudy: The reduction of risk of the occurrence of death, any stroke, or myocardial infarction within 30 days (myocardial infarction was defined as a post-interventional cardiac troponin T level increase >2-fold the upper limit of normal in addition to either chest pain or symptoms consistent with ischemia or electrocardiographic evidence of ischemia) between CEA and CS groups.



Other Outcome Measures:
  • Complications [ Time Frame: 24 hours and 30 days after intervention ] [ Designated as safety issue: Yes ]
    Any complication during CEA and CS, sonolysis or 30 days after intervention in all subgroups.


Estimated Enrollment: 240
Study Start Date: October 2010
Estimated Study Completion Date: March 2015
Estimated Primary Completion Date: January 2015 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: CEA with sonolysis
endarterectomy with sonolysis (continual transcranial Doppler monitoring)
Procedure: sonolysis
continual transcranial Doppler monitoring with max. diagnostic intensity for 60 minutes
Other Names:
  • sonolysis
  • sonothrombolysis
  • sonothrombotripsy
Procedure: endarterectomy
carotid endarterectomy
Other Name: carotid endarterectomy
Placebo Comparator: CEA without sonolysis
endarterectomy without sonolysis
Procedure: endarterectomy
carotid endarterectomy
Other Name: carotid endarterectomy
Experimental: carotid stenting with sonolysis
carotid stenting with sonolysis (continual transcranial Doppler monitoring)
Procedure: sonolysis
continual transcranial Doppler monitoring with max. diagnostic intensity for 60 minutes
Other Names:
  • sonolysis
  • sonothrombolysis
  • sonothrombotripsy
Procedure: carotid stenting
percutaneous transluminal angioplasty and stenting
Other Names:
  • carotid stenting
  • percutaneous transluminal angioplasty and stenting
  • PTAS
Placebo Comparator: carotid stenting without sonolysis
carotid stenting without sonolysis
Procedure: carotid stenting
percutaneous transluminal angioplasty and stenting
Other Names:
  • carotid stenting
  • percutaneous transluminal angioplasty and stenting
  • PTAS

  Hide Detailed Description

Detailed Description:

AIM OF THE PROJECT AND HYPOTHESIS The aim of the project is to demonstrate an effect of continual TCD monitoring using 2 MHz diagnostic probe with maximal diagnostic energy on the reduction of risk of brain microinfarctions due to the activation of endogenous fibrinolytic system during CEA and CS. The second aim of the study is to compare the risk of brain infarction between CEA and CS.

240 patients indicated for CEA (120 patients) and CS (120 patients) will be enrolled into the study in order to demonstrate a twenty-percent risk reduction of number and volume of brain infarctions detected using MRI examination 24 hours after CEA or CS in 5% level of statistical significance. Patients will be randomized into 2 subgroups. Subgroup 1 will undergo a 60minute non-diagnostic TCD monitoring during CEA or CS. Subgroup 2 will undergo CEA or CS without TCD monitoring. The second aim is to compare number and volume of brain infarctions detected using MRI between CEA and CS patients.

Substudy "Risk of brain infarction after carotid endarterectomy and stenting" The aim of the prospective, randomized study was to compare the risk of asymptomatic and symptomatic brain infarctions, changes in cognitive functions, as well as morbidity and mortality at 30 days between patients with symptomatic and asymptomatic severe ICA stenoses undergoing elective CEA and CAS.

PATIENTS AND METHODS 240 patients with ICA stenosis indicated for CEA or CS according to the criteria of the American Heart Association will be enrolled into the study during a 4-year period. Altogether 120 patients indicated for CEA and 120 patients indicated for CS will be randomized for standard CEA / CS and TCD monitored CEA / CS.

Randomization: Randomization using computer generated random allocation will be used, separately for CEA and CS patients.

Substudy "Risk of brain infarction after carotid endarterectomy and stenting" Minimally146 patients with ICA stenosis >70% (symptomatic or asymptomatic) detected by duplex sonography and confirmed using computed tomography angiography (CTA); indication for carotid intervention (CEA or CAS) according to criteria set by the American Heart Association5; age 40-80 years; (iv) functionally independent (modified Rankin score 0-2 points); no contraindication to magnetic resonance imaging (MRI), CTA or digital angiography (DSA) will be enrolled to the Substudy.

Randomization: Randomization using computer generated random allocation to CEA or CS will be used.

Sonothrombolysis: In patients randomized into sonothrombolysis subgroup, MCA segment in depth 55 mm will be monitored for 40 minutes using a diagnostic 2 MHz probe with maximal diagnostic energy. Non-diagnostic TCD monitoring will be performed without detection of microembolic signals or detection of changes in blood flow. The second (control) subgroup will undergo a standard CEA or CS without sonothrombolysis.

MRI protocol will consists of 4 sequences: 1. Localizer; 2. T2TSE; 3. FLAIR; 4. DWI. Sequences 1-3 will be applied in the same level, they will have the same slice thickness and the same cut number. The slice thickness comprises its own cut thickness (5 mm) + distant factor (30%). Standard number of slices is 19. Standard slice level is considered to be a modified level of skull base due to the minimalization of distant artifacts EPI sequence. T2TSE: TR=4000/TE=99/ETL=9, FOV 230, FOV ph. 75%, matrix 256x256. FLAIR: 8050/112/ETL=21/2 conc., FOV 230, FOV ph. 76,6%, matrix 256x151. EPI-DWI: 4200/139/EPI f.=96/6 av., FOV 230, FOV ph. 100%, phase enc. direction A-P, matrix 128x96 with interpolation, phase partial Fourier 6/8, Bw 1346 Hz/Px, echo spacing 0.83 ms, TA. Sequence called "trace" with three types of MR pictures in every slice: (a) T2*EPI b=0; (b) DWI b=500; (c) DWI b=1000. The fourth type of images automatically created an ADC map (in-line postprocessing). DWI show a middle (average) diffusivity of every point of examined brain tissue when b value is 500 and 1000. This sequence is applied in order to assess hemorrhage (T2*EPI) and monitor sites of reduced diffusion (DWI, b=500 and 1000). New infarctions will be evaluated only in the territory of treated ICA.

Adverse effects: All adverse effects during 1 month after UM will be registered, especially all causes for new admissions to the hospital, worsening of neurological symptoms (>4 points in NIH stroke scale), brain edema, symptomatic and asymptomatic intracranial bleeding detected in control brain MRI.

Statistic evaluation: All statistical tests will be performed at the Department of Biophysics, Informatics and Biometry, Palacký University Medical School, Olomouc. Statistical evaluation in 5% level of significance of differences in the number and volume of brain infarctions detected using MRI between patients with TCD monitoring and without TCD monitoring during CEA or CS will be performed using Student T-test, χ2-test, Mann-Whitney U-test, ANOVA and multivariate analysis. Differences in the number and volume of brain infarctions between patients after CEA and CS will be evaluated as secondary end-points. Influence of other factors, e.g. age, gender, symptoms in the territory of treated artery, number of infarctions before CEA or CS, results of cognitive tests will be evaluated.

Statistic evaluation for Substudy: The normality of distribution of all data will be checked using the Shapiro-Wilk test. Categorical variables in the two arms will be compared by Fisher's exact test. Continuous variables will be compared by the Student's t-test for normally distributed values and by Mann-Whitney U test for other values. Multiple logistic regression analyses were used to determine the possible predictors of a new brain infarction. All tests were carried out at an alpha level of significance of 0.05.

Study protocol has been approved by the Ethics Committees in accordance with the principles and guidelines of the Declaration of Helsinki, 1975.

  Eligibility

Ages Eligible for Study:   40 Years to 80 Years
Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • stenosis of internal carotid artery
  • indication to endarterectomy or stenting
  • age 40-80 years
  • sufficient temporal bone window for TCD with detectable blood flow in MCA
  • independent patient (modified Rankin score 0-2)
  • informed consent signed by the patient.

Exclusion Criteria:

  • contraindication to MRI examination (pace-maker, implanted metal material, claustrophobia)
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01591005

Contacts
Contact: David Skoloudik, MD, PhD 00420597375613 skoloudik@hotmail.com
Contact: Martin Kuliha, MD 00420597375630 martin.kuliha@email.cz

Locations
Czech Republic
University Hospital Ostrava Recruiting
Ostrava, Czech Republic, 70852
Contact: David Skoloudik, MD, PhD    00420597375613    skoloudik@hotmail.com   
Contact: Martin Kuliha, MD    00420597375630    martin.kuliha@email.cz   
Principal Investigator: David Skoloudik, MD, PhD         
Sponsors and Collaborators
University Hospital Ostrava
Palacky University
Investigators
Principal Investigator: David Skoloudik, MD, PhD University Hospital Ostrava
  More Information

Additional Information:
No publications provided

Responsible Party: Vaclav Prochazka, MD, PhD. MSc, Vaclav Prochazka, MD, PhD, MSc, University Hospital Ostrava
ClinicalTrials.gov Identifier: NCT01591005     History of Changes
Other Study ID Numbers: NT11386-5/2010
Study First Received: April 23, 2012
Last Updated: April 9, 2014
Health Authority: Czech Republic: Ethics Committee

Keywords provided by University Hospital Ostrava:
sonolysis
carotid
endarterectomy
stenting

Additional relevant MeSH terms:
Infarction
Carotid Stenosis
Brain Infarction
Ischemia
Pathologic Processes
Necrosis
Carotid Artery Diseases
Cerebrovascular Disorders
Brain Diseases
Central Nervous System Diseases
Nervous System Diseases
Arterial Occlusive Diseases
Vascular Diseases
Cardiovascular Diseases
Brain Ischemia
Stroke

ClinicalTrials.gov processed this record on September 18, 2014