Trial of PCSK9 Inhibition in Patients With Acute Stroke and Symptomatic Intracranial Atherosclerosis

Phase 2

Recruiting

• Conditions: Intracranial Atherosclerosis; Acute Ischemic Stroke; ICAS - Intracranial Atherosclerosis
• Interventions: Drug: Alirocumab

• Registration Number: NCT05001984
• Lead Sponsor: Chang Gung Memorial Hospital

Brief Summary

This study will evaluate whether low-density lipoprotein (LDL-C) lowering with alirocumab results in greater change from baseline in intracranial atherosclerotic plaque at week 26 than control in adults with acute ischemic stroke from intracranial atherosclerosis taking lipid lowering therapy.

Detailed Description

In this trial, we will conduct a prospective, randomized, open-label, blinded end-point study using high-resolution MRI in patients with acute ischemic stroke from intracranial atherosclerosis to evaluate the efficacy and safety of alirocumab. We hypothesis that additional alirocumab treatment on a background of statin therapy could result in greater stabilization of intracranial plaque and regression of arterial stenosis.

Study Timeline

• Study First Submitted: 2021-07-22
• Study Start: 2021-08-01
• Study First Submitted QC: 2021-08-09
• Study First Posted: 2021-08-12
• Status Verified: 2023-09
• Last Update Submitted: 2023-09-05
• Last Update Posted: 2023-09-06
• Primary Completion: 2024-08-30
• Study Completion: 2024-12-31

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 60

Inclusion Criteria

• Clinical diagnosis of ischemic stroke with National Institutes of Health Stroke Scale (NIHSS) score of 1-15
• Ischemic lesions on diffuse-weighted imaging located in the territory of symptomatic intracranial atherosclerosis (ICAS).
• Symptomatic ICAS (above 30%) at the M1 or M2 of the middle cerebral artery, basilar artery or at the intracranial portion of the internal carotid artery or vertebral artery.
• Serum LDL-C ≥70 mg/dL for subjects on lipid-lowering therapies (such as a statin and/or ezetimibe) or LDL-C ≥100 mg/dL for subjects without lipid-lowering therapies.
• Ability to randomize within 7 days of time last known free of new ischemic symptoms.
• Ability to receive alirocumab or statin treatment within 7 days of stroke onset.
• Head CT or MRI ruling out hemorrhage or other pathology, such as vascular malformation, tumor, or abscess, that could explain symptoms or contraindicate therapy.
• Pre-stroke modified Rankin Scale (mRS)≦2

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Exclusion Criteria

• Age <20 years.
• Judged by clinical physician.
• After endovascular intervention or endarterectomy for the symptomatic ICAS.
• Patients with more than 50% stenosis of extra-cranial arteries the relevant arteries on magnetic resonance angiography (MRA), including extra-cranial carotid artery or vertebral arteries.
• Patients with high risk of cardioembolic source, such as atrial fibrillation, acute myocardial infarction, severe heart failure or valvular heart disease.
• Other determined stroke etiology, such as vasculitis, shock, antiphospholipid antibody syndrome, arterial dissection, CADASIL and etc.
• Qualifying ischemic event induced by angiography or surgery.
• Severe non-cardiovascular comorbidity with life expectancy <6 months.
• Contraindication or allergy to alirocumab or Gadolinium
• Severe renal (serum creatinine >2 mg/dL) or calculated glomerular filtration rate <30 mL/min/ 1.73 m2 by estimated glomerular filtration rate (eGFR) using Cockcroft Gault methodology.
• Hepatic insufficiency (INR>1.2; ALT>40 U/L or any resultant complication, such as variceal bleeding, encephalopathy, or jaundice)
• Hemostatic disorder or systemic bleeding in the past 3 months
• Current thrombocytopenia (platelet count <100 x109/L) or leukopenia (<2 x109/L)
• Anemia（<10 mg/dL）
• History of drug-induced hematologic or hepatic abnormalities
• History of malignancy that required surgery, radiation therapy or systemic therapy.
• Females who are pregnant or nursing, or who are of childbearing potential and unwilling to use effective contraception.
• Other neurological conditions that would complicate assessment of outcomes during follow-up.

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Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Intervention group	Alirocumab	In addition to high-intensity statin and antiplatelet treatment, patients will receive treatment of alirocumab 75mg subcutaneously every 2 weeks for a total of 26 weeks

Primary Outcome Measures

Name	Time	Method
The changes of intracranial atherosclerotic plaque: stenosis degree	26 weeks	The changes of intracranial atherosclerotic plaque in vessel-wall MRI before and after 6-month treatment, measured as stenosis degree.; The degree of stenosis was calculated as: (1-lumen area of stenotic lesion/reference lumen area)×100%.
The changes of intracranial atherosclerotic plaque: percent atheroma volume	26 weeks	The changes of intracranial atherosclerotic plaque in vessel-wall MRI before and after 6-month treatment, measured as percent atheroma volume (PAV).; The PAV was calculated using the following equation: PAV = Σ(EEM area - Lumen area) / ΣEEM area × 100, where EEM area is the cross-sectional area of the external elastic membrane and Lumen area is the cross-sectional area of the lumen.
The changes of intracranial atherosclerotic plaque: enhancement volume	26 weeks	The changes of intracranial atherosclerotic plaque in vessel-wall MRI before and after 6-month treatment, measured as enhancement volume.; The enhancement volume was measured as post-contrast plaque enhancement for intracranial arteries and intraplaque hemorrhage.

Secondary Outcome Measures

Name	Time	Method
Changes in serum biomarkers	26 weeks	Include liver function tests, HbA1c and lipid profiles.
Percentage of patients with major cardiovascular events	26 weeks	Defined as the composite of cardiovascular death, myocardial infarction, transient ischemic attack, ischemic stroke and hemorrhagic stroke.
Percentage of patients with myocardial infarction	26 weeks	patients with myocardial infarction
Percentage of patients with cardiovascular death	26 weeks	patients with cardiovascular death
Percentage of patients with new ischemic lesions	26 weeks	Defined as new ischemic lesions in the territory of ICAS between 2 MRIs
Percentage of patients with stroke	26 weeks	Include transient ischemic attack, ischemic and hemorrhagic stroke
Percentage of patients with ischemic stroke or transient ischemic attack.	26 weeks	Percentage of patients with ischemic stroke or transient ischemic attack.
Percentage of patients with favorable functional recovery	3 months	Defined as a mRS ≦2 mRS. The Modified Rankin Scale (mRS) runs from 0-6, running from perfect health without symptoms(score 0) to death(score 6).

Trial Locations

Locations (1)

Yenchu Huang; 🇨🇳 Chiayi City, Taiwan