Qiang Dong

1. Department of Neurology, Huashan Hospital, Fudan University

^*Corresponding author: Qiang Dong (on behalf of GISAA research committee), No.12 Wulumuqi Middle Road, Shanghai 200040, China

Abstract

Introduction: Intracranial stenosis in ischemic stroke is a major medical challenge in China. Large atherosclerotic ischemic stroke is the most common type of cerebral infarction. Ginkgolide is one of potential neuroprotection agents in stroke patients, Preclinical studies have demonstrated that it improves outcomes in stroke patientswith low rate of any adverse events. The efficacy and safety of ginkgolide in stroke patients with large artery atherosclerotic are still unspecified. Method: GISAA is a randomized, double-blinded, multicenter, placebo-controlled of Post marketing clinical study. A total of 878 Chinese patients with Large atherosclerotic ischemic stroke will be enrolled. All patients receive ginkgolide/ placebo by intravenous drip once daily for 14consecutive days. Primary outcome includes the recurrence stroke rate and mortality rate. Secondary outcomes include functional improvement measured by the National Institutes of Health Stroke Scale, Barthel index and modified Rankin Scale. Moreover, the platelet aggregation rate would be measured as the concentration of PAF, TXA2, and ADP.Discussion: The ongoing Ginkgolide in Ischemic Stroke patients with large Artery Atherosclerosis(GISAA)trial is designed to evaluate the efficacy and safety of Ginkgolide in Chinese patients with Large atherosclerotic ischemic stroke.Data from large-scale clinical studies are still unavailable concerning the post-marketing use of ginkgolide. Trial Registration: The study has prospectively registered on www.chictr.org.cn(ChiCTR-IPR-17012310).

Keywords: atherosclerosis, ischemic stroke, ginkgolide, protocols, post marketing clinical study

Background

TheGlobal Burden of Disease2013 study showed that although stroke incidence, prevalence, mortality, and disability-adjusted life-years rates tended to decline from 1990 to 2013, the absolute number of people who had astrokeevery year, strokesurvivors, related deaths, and the overallglobalburdenofstroke were great and increasing, particularly in low-to-middle income countries [1].In China, stroke is the second leading cause of death, andischemic strokeis the most common stroke subtype. According to the Trial of Org 10172 in Acute Stroke Treatment (TOAST), stroke is classified into large artery atherosclerotic type, cardiogenic cerebral embolism, small artery block type, lacunar stroke, other causes and ischemic stroke of unknown cause. Tsai CF et al reported that the proportion of strokes due to Large Artery Atherosclerosis (LAA) ranged from 12% to 54%, small vessel disease 20% to 42%, cardioembolism 10% to 26%, and the combination of other specific determined and undetermined etiology subtypes 4% to 34% [2]. Of all ischemic strokes,LAA of the headand neck is responsible for approximately 15% of stroke [3].However, LAA is the leading stroke subtype in China[4].In many Asian countries, LAA often affects the middle cerebral artery, intracranial portion of the internal carotid artery, and vertebrobasilar artery, which is estimated to 33%-50% of stroke in Chinese stroke populations [5]. The risk of early recurrent stroke is high in those patients with LAA. It has been reported that the risk of recurrent stroke might be as high as 8-12% in the first 7 days, [6] and 12%-14% during a 2-year follow-up, [7]even with the standard therapy. The annual risk may exceed 20% in stroke patients with LAA [7]. Carotid endarterectomy and stenting are both effective at reducing risk of recurrent stroke in patients with extracranial carotid, while limited intervention was warranted to be done in patients with intracranial artery stenosis.

As known, platelets have a crucial role in triggering arterial thrombosis [8] and in promoting atherogenesis [9], and also playa critical role in the pathogenesis of ischemiastroke. Microembolicsignals are common in patients with LAA [10] and are an independent marker of recurrent stroke [11].As a result, clinical guidelines recommend antiplatelet therapy for patients with non-cardioembolic stroke [12].Not only doesantiplatelet therapy decrease the risk of recurrent stroke, but reduce the risk of neurological deterioration.

Previousanimalstudy showed that ginkgolide injection could antagonism PAF-induced platelet aggregation, inhibitsthe activation ofplatelets, andis a kind of importantantiplatelet aggregation drug [23].Data in animal study have suggested that ginkgolide injection combined with aspirin, clopidogrel could produce cooperative effects to prevent PAF-induced platelet aggregation. [24] We hypothesize that their combination may have additive effects on platelet. Clinical studies have demonstrated the efficacy of ginkgolide injection in the treatment of ischemic stroke, and it can effectively improve the outcome of stroke patients [25,26].Herein, we planned to perform arandomized,double-blinded,multicenter,placebo-controlledtrial, which evaluated the effects ofcombined ginkgolide and aspirin therapy relative toaspirin monotherapy on clinical outcome and platelet activation in ischemic stroke patients with LAA.

Objective

The GISAA trial is to evaluate the effect of Ginkgolide in reducingclinical outcome in Chinese patients withlarge artery atherosclerotic ischemic stroke.

Design

GISAA is a randomized,double-blinded,multicenter,placebo-controlledtrial (Figure1).Patients enrollment plannedto begin at 50 strokecentersacross China from May 2016. The planned enrollment is878 patients with ischemic stroke involvinglarge-artery stenosis. Thepresent study was approved by the central ethics committeeat the leading study center atHuashan Hospital, Fudan Universityand by all the ethics committees at all participatingsites. Informed written consents were planned to obtain from patientsor their legal surrogates. The study performs followed the provisionsof the ICH Good Clinical Practice (GCP) and theDeclaration of Helsinki.

Figure 1.

Study Population and Allocation

The inclusion and exclusion criteria of patients are summarized in Table 1.Randomized block was used to allocated patients and the random allocation scheme1:1 treatment group and control group, was made by using SAS9.1.3 software. The generate random encoding by using randomized method, block selection and the length of the random initial value parameters such as seeds of confidential data are sealed together in blind bottom. Patients were also stratified by their baseline severity and risk factors. According to this random number, the drug is coded by the person who has nothing to do with the test. Each clinical research center was allocated according to the assigned drug number and selected according to the case order. There were two copies of blind bottom, which were respectively located in Department of Neurology, Huashan Hospital, Fudan Universityand Chengdu hundred pharmaceutical co. Ltd.

Table 1.

Sample Size Estimates

The sample size of this study is estimated based on rate of recurrence stroke, mortality within 28 days in the Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR) study [27]. Using PASS11.0 software to calculate the sample content, we used threshold value as 0.010 with α=0.025(unilateral side) and β=0.20. We derived the expected sample sizeof this study accordingly is 732 samples, 366 samples in each group. Considering the possibility of dropout during clinical trials an increase of 20% based on the estimated value of sample size formula, the total sample size was 878 with 439 casesin each group.

Taking into account the number of patients in the GISAA trial and incidence of ischemic stroke patients with LAA in China, we plan to complete the trial in two year. Between May 2016 and Dec 2018, 878 patients will be randomized (439 in theginkgolide plus aspirin group and 439 in the aspirin plus placebo group) at 43 centers in China.

Interventions

Patients were screened after inclusion of exclusion criteria. All patients met the inclusion criteria were randomly assigned to receive aspirin100mg oral daily combined with intravenousginkgolide 10ml for 14 days or aspirin 100mg oral daily combined with placebo. Intravenous ginkgolide and placebo were labeled with same drug label, and the drug was identical in appearance.

During the present study, anticoagulants, any other thrombolytic drugs, Chinese traditional medicine for promoting blood circulation to dissipate blood stasis and apoplexy treatment, and other antiplatelet aggregation drugs other than aspirin are prohibited. Treatment of combined diseases, such as antihypertensive drugs, hypoglycemic drugs, lipid-lowering drugs and so on were allowed to be used followed by the physician recommendations.The detailed follow-up schedule of study is shown in Table 2.

Table 2.

Outcome

The rate of stroke recurrence and mortality were followed-up within 28 days after randomization [28]:Recurrent stroke were defined as an index event (ischemic or hemorrhagic) after 24 hours of randomization or NIHSS increasing more than 4 points.Ischemic stroke was defined as an acute focal infarction of the brain or retina with one of the following: sudden onset of a new focal neurologic deficit,with clinical or imaging evidence of infarction lasting 24 hours or more and not attributable to a nonischemic cause (i.e., not associated with brain infection, trauma, tumor, seizure, severe dynamic disorders, or degenerative neurologic disease);a new focal neurologic deficit lasting for less than 24 hours and not attributable to a nonischemic cause but accompanied by neuroimaging evidence of new brain infarction; or rapid worsening of an existing focal neurologic deficit lasting more than 24 hours and not attributable to a nonischemic cause, accompanied by new ischemic changes on MRI or CT of the brain and clearly distinct from the index ischemic event. Hemorrhagic stroke was defined as acute extravasation of blood into the brain parenchyma or subarachnoid space with associated neurologic symptoms.

We assessed two aspects of secondary clinical outcome. (1)The improvementof clinical symptoms measured byNational Institute of Health stroke scale(NIHSS) score at 14 and 28 days after randomization.(2)The improvement of functional outcome assessed by modified Rankin scale score (mRS)at 28 days after randomization.

The NIHSS is a tool used by healthcare providers to objectively quantify the impairment caused by a stroke. The NIHSS is composed of 11 items, ranged from 0 to 42 points.For each item, a score of 0 typically indicates normal function in that specific ability, whereas a higher score is indicative of some level of impairment. The individual scores from each item are summed to calculate a patient’s total NIHSS score. The maximum possible score is 42, with the minimumof 0.

The mRS is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke. The scale runs from 0 to 6, running from perfect health without symptoms to death.

1. No symptoms.

2. No significant disability: able to carry out all usual activities, despite some symptoms.

3. Slight disability: able to look after own affairs without assistance, but unable to carry out all previous activities.

4. Moderate disability: requires some help, but able to walk unassisted.

5. Moderately severe disability: unable to attend own bodily needs without assistance, and unable to walk unassisted.

6. Severe disability: requires constant nursing care and attention, bedridden, incontinent.

7. Dead.

Huashan Hospital were responsible for training all assessment and measurements, and all researchers need to have a certificate of training before their first patient enrollment.

Patientsplatelet aggregation rate was induced by PAF, TXA2, and ADP, at baseline (-3 days-0 days), 7days and 28 days after randomization, respectively. Central Laboratory were in charge of testing their platelet aggregation rate with standard protocol.

The incidence of bleeding events (radiographic examination combined with bleeding symptoms) and adverse events in the two groups.

Data Quality Assurance and Control

The case report formswouldbe filled out by the researchers, and each case must be completed with a case report form. The case report form by the clinical research assistant(CRA) examination, give the data administrator for data entry and management work. Data administrator establishes recorded data storage by EpiData 3.0 software. In order to ensure the accuracy of the data, the clinical research centers and Data Administrators independently carry out double entry and proofread. The clinical research center of the data administrator is responsible for the audit quality of the case report form, review of qualified data must be complete entry and upload to the Internet within a week. If there is any doubt, requirement table was built up and questions would be raised to researchers by the CRA. Allresearchers should response to questions as soon as possible. Data administrator according to the researcher's answer for data validation and input.

After confirming that the database was established correctly, the data were locked by the principal researcher, the applicant, and the statistical analyst. The locked data file is no longer altered.

Statistical Analyses

The statistical analyses are performed by Department of Epidemiology and Health Statistics, Huaxi School of Public Health, Sichuan University. Analysis of continuous variables will be described by Student’s t test. For the analysis of (co)variance or in case of skewed distributions which cannot be normalized by log transformation, corresponding nonparametric tests will be used. Chi-squared test will be used for analysis of categorical variables and logistic regression analyses will be used to adjust for potential confounding factors.

Quality Control and Data Storage

To ensure the supervision of clinical research quality control and measurement, researchers should agree to all research data preservation, including confirmation of subjects (can effectively check the record data, such as case report forms and hospital original records). The preserve time is 5 years.

All patients’ information of this clinical studybelongs to the researchers. The Research Committee is responsible for all clinical research implication, interpretation and data reporting.

Role of the Funding Source

All interventions and placebos were sponsored by Chengdu hundred pharmaceutical co. Ltd. Otherwise, the sponsor does not play a role in the study design, data collection, data analysis, data interpretation, or data reporting.The members of Data and Safety Monitoring Board were selected by the research committee, were in place to ensure the safety of patients during the study, with predetermined periodic assessments of safety and terminate rules.

Discussion

The neuroprotection of ginkgolide has been published, however, the ginkgolide combined with aspirin in acute ischemic stroke with LAA was unclear. We hypothesis that the combination of ginkgolide and aspirin can reduce the recurrence stroke rate and mortality, compared to aspirin alone in patients with LAA.

Except the clinical benefit, GISAA trial also explores the relationship between the level of platelet activation and neurological deterioration. We hypothesize that the platelet aggregation induced by PAF, TXA2 or ADP would be lower in patients who does not have subsequent neurological deterioration and recurrent stroke.

It is common that LAA patients were commonly worsening and more likely to recurrent, even with aspirin, which is the widely used and reduces stroke risk by 18% [13]. On the other hand, the present data suggested that aspirin non-responder status was need to considered as suspected in approximately 30–40 % of patients with recurrent cerebrovascular ischemic events despite regular use of aspirin [14].The 2-year recurrent ischemic stroke rates are 19.7% in stroke patients with LAA, in spite of aspirin therapy [15].Therefore,combinationtherapymight be helpful to reduce the incidence of recurrent ischemic stroke or neurologic deterioration. However,combination treatment with aspirin and anticoagulation (warfarin/low-molecular-weight heparin) was also no more effective than aspirin alone in preventing recurrent stroke or reducing neurological deterioration [16-18].Combined antiplatelet therapy is supposed to be more clinical benefit compared with aspirin and placebo. The CHANCE(Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events) trial and a following meta-analysis showed that clopidogrel plus aspirin versus aspirin alone initiated in early period significantly reduced risk of recurrent stroke with no increase in major hemorrhage [19,20].

However, The COMPRESS (Combination of Clopidogrel and Aspirinfor Prevention of Recurrence in Acute AtherothromboticStroke Study) trialshowedthat patients with acute ischemic stroke of presumed LAA origin within 48 hoursof onset, adding clopidogrel to aspirin for 30 days comparedwith aspirin alone did not reduce the risk of developing newischemic lesions, clinical stroke recurrence, composite major vascular events, and functional disability [21].The main reasons of these debating resultsarethat CHANCE enrolled patients are within 24 hours of onset and COMPRESS did not use a clopidogrel loading dose because of safety concerns.The ginkgolide, as a safety and effective therapy, might be benefit for acute stroke patients with LAA.Our GISAA trial wouldprovide an evidence that the ginkgolide combined with antiplatelet therapy has a potential benefit in patients with an ischemic stroke with LAA in short term treatment.

Abbreviations

GISSA: Ginkgolide in Ischmic Stroke patients with large Artery Atherosclerosis; TOAST: Trial of Org 10172 in Acute Stroke Treatment; GCP: Good Clinical Practice; CHANCE: Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events; COMPRESS: Combination of Clopidogrel and Aspirin for Prevention of Recurrence in Acute Atherothrombotic Stroke Study; LAA: Large Artery Atherosclerosis; CRA:clinical research assistant; NIHSS: National Institute of Health stroke scale; CLAIR: Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis

Ethics Approval and Consent to Participate

Huashan Hospital IRB has approved this study protocol.

Consent for Publication

Not available

Availability of Data and Material

Not available

Competing Interests

All interventions and placebos were sponsored by Chengdu hundred pharmaceutical co. Ltd. Otherwise, the sponsor does not play a role in the study design, data collection, data analysis, data interpretation, or data reporting. There is no other conflict of interest.

Funding

All interventions and placebos were sponsored by Chengdu hundred pharmaceutical co. Ltd.

Authors’ Contribution

Qiang Dong designed and draft the protocol. GISAA research committee includes Dr. Liu Ming from West China Hospital, Dr. Yi Yang from the first hospital affiliated to Jilin University, Dr. Yun Xu From Gulou Hospital, Dr. Xin Wang from Zhongshan Hospital affiliated to Fudan University, Dr. Fan Jun from 202 Hospital, Dr. Bo Xiao from Xiangya Hospital Central South University, Dr Linhong Feng from the first hospital affiliated to Harbin Medical University, Dr Anding Xu from the first hospital affiliated to Jinan University. They have participated and approved the protocol after revision.

Acknowledge

Not available.

References

1. Vos T, Barber RM, Bell B, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries,1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743-800.

2. Tsai CF, Thomas B, Sudlow CL. Epidemiology of stroke and its subtypes in Chinese vs white populations: a systematic review. Neurology. 2013; 81: 264–72.

3. Cole JW. Large Artery Atherosclerotic Occlusive Disease.Continuum (Minneap Minn). 2017;23(1, Cerebrovascular Disease):133-157.

4. Lv P, Jin H, Liu Y, et al.Comparison of Risk Factor between Lacunar Stroke and Large Artery Atherosclerosis Stroke: A Cross-Sectional Study in China.PLoS One. 2016;11(3):e0149605.

5. Philip B. Gorelick, Ka Sing Wong, et al.Large Artery Intracranial Occlusive DiseaseA Large Worldwide Burden but a Relatively Neglected Frontier.Stroke. 2008;39(8):2396-9.

6. Rothwell PM, Buchan A, Johnston SC. Recent advances inmanagement of transient ischaemic attacks and minor ischaemicstrokes. Lancet Neurol. 2006; 5: 323–31.

7. Qureshi AI, Feldmann E, Gomez CR, et al.Intracranial atherosclerotic disease: anupdate. Ann Neurol. 2009;66(6):730-738.

8. Ruggeri ZM. Platelets in atherothrombosis. Nat Med. 2002;8(11):1227-1234.

9. Fateh-Moghadam S, Li Z, Ersel S, et al. Platelet degranulation is associated with progression of intima-media thicknessof the common carotid artery in patients with diabetes mellitus type 2. Arterioscler Thromb Vasc Biol. 2005;25(6):1299-1303.

10. King A, Markus HS. Doppler embolic signals in cerebrovasculardisease and prediction of stroke risk: a systematic review andmeta-analysis. Stroke. 2009; 40: 3711–17.

11. Gao S, Wong KS, Hansberg T, Lam WW, Droste DW,Ringelstein EB. Microembolic signal predicts recurrent cerebralischemic events in acute stroke patients with middle cerebral arterystenosis. Stroke. 2004; 35: 2832–36.

12. FurieKL,KasnerSE,AdamsRJ,etal.UpdatetotheAHA/ASArecommendations for the prevention of stroke in patients with strokeandtransient ischemic attack. Stroke. 2008;39(5):1647-1652.

13. Xu Lu, Huang Yan. The effects of bai yu ginkgolide injection on platelet aggregation in rabbits. JETCM.2014;23(4):638-643.

14. Xu Lu, Zhang Taijun. The effects of bai yu ginkgolide injection combined with aspirin, clopidogrel on platelet aggregation and ultra structure changes. J Zunyi Medical University.2015;38(1):25-28.

15. Yuxia Z. Clinical observation on treating cerebral infarction with ginkgolide. Clinical Journal of Chinese Medicine.2017;9(1):92-94.

16. Li Cong, Dai Yingjie, Guo Wei, et al. Clinical study on Ginkgo biloba lactone injection combined with rt-PAintravenous thrombolysis in treatment of acute ischemic stroke. Drug Evaluation Research.2017;40(6):764-768.

17. Ka Sing Lawrence Wong, Christopher Chen, Jianhui Fu, et al.Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR study): a randomised,open-label, blinded-endpoint trial. Lancet Neurol. 2010;9(5):489-97.

18. Yongjun Wang , Yilong Wang, Xingquan Zhao et al. Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack. New England J Med.2013.6:1-9.

19. Diener HC, Cunha L, Forbes C, et al. European stroke prevention study 2: dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci.1996;143(1-2):1-13.

20. Grundmann K, Jaschonek K, Kleine B, et al. Aspirin non-responder status in patients with recurrent cerebralischemic attacks. J Neurol. 2003;250:63-66.

21. Chimowitz MI, Lynn MJ, Howlett-Smith H, et al. Warfarin–Aspirin Symptomatic Intracranial Disease Trial Investigators. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. N Engl J Med. 2005;352:1305–1316.

22. Chimowitz MI, Lynn MJ, Howlett-Smith H, et al. Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis.N Engl J Med. 2005; 352: 1305–16.

23. Wong KS, Chen C, Ng PW, et al. Low-molecular-weight heparin compared with aspirin for the treatment of acute ischaemic stroke in Asian patients with large artery occlusive disease: a randomized study. Lancet Neurol. 2007; 6: 407–13.

24. Kwon SU, Cho YJ, Koo JS, et al. Cilostazol prevents the progressionof the symptomatic intracranial arterial stenosis: the multicenterdouble-blind placebo-controlled trial of cilostazol in symptomaticintracranial arterial stenosis. Stroke 2005; 36: 782–86.

25. Wang Y, Wang Y, Zhao X, et al. CHANCE Investigators. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369:11–19.

26. Wong KS, Wang Y, Leng X, et al. Early dualversus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke or transient ischemic attack: an updated systematic reviewand meta-analysis. Circulation. 2013;128:1656–1666.

27. Hong KS, Lee SH, Kim EG, et al. Recurrent Ischemic Lesions After Acute Atherothrombotic Stroke :Clopidogrel Plus Aspirin Versus Aspirin Alone.Stroke. 2016;47(9):2323-30

Received: : Novemeber 28, 2018;
Accepted: December28, 2018;
Published: December31, 2018.

To cite this article : Qiang Dong. Ginkgolide in Ischmic Stroke patients with large Artery Atherosclerosis(GISAA):A randomized, double-blinded, multicenter, placebo-controlled study. British Heart Diseases.2020;2:1.

© Dong Q. 2020.