REperfusion With P2Y12 Inhibitors in Addition to mEchanical thRombectomy for perFUsion Imaging Selected Acute Stroke patiEnts (REPERFUSE)

Fondation Ophtalmologique Adolphe de Rothschild

Status and phase: Enrolling; Phase 3

Conditions: Acute Ischemia

Treatments: Other: best medical management; Drug: Cangrelor

Study type: Interventional

Funder types: Other; NETWORK

Identifiers

NCT04667078

MMI_2020_35

Details and patient eligibility

About

The main objective is to evaluate the efficacy of IV administration of the P2Y12 inhibitor (cangrelor) in addition to mecanich thrombectomy and WMD versus mecanich thrombectomy and WMD alone on the functional prognosis at 3 months, in patients with acute ischemic stroke eligible for mecanich thrombectomy on the basis of infusion imaging between 0 and 24 hours after the onset of symptoms.

Full description

The emergent reperfusion of the ischemic penumbra is the goal of acute ischemic stroke (AIS) treatment. Mechanical thrombectomy (MT) may be proposed up to 6 hours and from 6 to 24 hours after stroke onset if multimodal imaging demonstrates the presence of a substantial ischemic penumbra.

Despite the major benefit associated with MT, more than half of patients will remain disabled at 3 months. The rate of complete reperfusion after MT appears to be a major factor affecting functional outcome. However, this rate of complete reperfusion is only achieved in 50 % of the patients due to, at least in part, distal microcirculatory impairment and or erratic emboli.

In coronary artery disease, new antiplatelet agents, with a very short half-life, such as P2Y12 inhibitors (P2Y12I), have been shown to reduce in-stent thrombosis, myocardial infarction and death. The IV route for P2Y12 inhibitors administration is adapted to the stroke population who has frequently dysphagia that prevents per os drug administration. In addition, the very short half-life of the drug is quite interesting for the management of hemorrhagic complications or emergent surgical interventions and early antithrombotic secondary prevention initiation.

Hypothesis: subgroup of patients treated from 0 to 24 hours after onset with a demonstrated ischemic penumbra on perfusion imaging, the administration of P2Y12I in addition to MT and best medical management (BMM) may increase reperfusion rates and improve functional outcome compared to MT with BMM alone.

Enrollment: 368 estimated patients

Sex: All

Ages: 18 to 80 years old

Volunteers: No Healthy Volunteers

Inclusion and exclusion criteria

Inclusion Criteria:

• Age 18 or older

• Anterior circulation intracanial large artery occlusion isolated (Intracranial ICA and/or MCA) proved on CTA or MRA.

• Symptoms onset < 24h at imaging

• Indication for MT and fulfillment of the following brain imaging criteria :

  1. Perfusion imaging: An initial infarct volume (ischemic core on DWI or CTP calculated by the RAPID software) of less than 70 ml, a ratio between the critically hypoperfused lesion volume (calculated by RAPID with a TMax>6s) and initial infarct volume of 1.8 or more, and an absolute difference between those 2 volumes of 15 ml or more.

     OR (if perfusion imaging not available or uninterpretable) :

  2. CORE CLINICAL MISMATCH: Core calculated on DWI by RAPID, <25 mL if NIHSS 6-20 and <50 mL if NIHSS>20

     OR (if RAPID results are not considered reliable by the clinician) :

  3. CORE CLINICAL MISMATCH according to the clinician evaluation

• Pre-stroke mRS ≤ 2

• NIHSS ≥ 6

Exclusion Criteria:- Contraindication to MT

• Contraindication to MT
• Patient over 80 years old with >10 microbleeds on pre-treatment MRI
• Pre-existing dependency with mRS ≥3.
• Known tandem ICA-MCA occlusions requiring stenting
• ASPECT<6 on NCCT or DWI-MRI
• Known hypersensitivity to cangrelor or to any of the excipients (mannitol, sorbitol)
• History of previous intracranial hemorrhage
• Evidence of active bleeding or acute trauma (fracture) on examination
• Recent surgery with a significant risk of bleeding
• VKA oral anticoagulation with INR >1.7
• Curative heparin or direct oral anticoagulants (DOACs) in previous 48 hours
• Platelet count <100 000/ mm3
• Women with childbearing potential (15-49 years old)
• Patient benefiting from a legal protection
• Non-membership of a national insurance scheme
• Opposition of the patient or (in case of inclusion as a matter of urgency) of the trustworthy person Participation in another study regarding AIS care interfering with this study

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

---

368 participants in 2 patient groups

Cangrelor group

Experimental group

Description:

treated by P2Y12 inhibitor (cangrelor) in addition to MT and BMM. The dose of cangrelor will be started with a 30 micrograms/kg IV bolus over 1 minute right after randomization and before MT. The bolus will be immediately followed with 4 micrograms/kg/min IV infusion for the duration of MT up to 4 hours. Cangrelor infusion will be stopped at the end of the MT procedure and will not go further 4 hours. Transition to oral antiplatelet therapy will be possible 1 hour after cangrelor infusion discontinuation. No other anti-thrombotic drug is authorized during cangrelor infusion. MT technique choice is left to the investigator decision.

Treatment:

Drug: Cangrelor

Best medical management group

Active Comparator group

Description:

treated by BMM associated to MT. Anti-thrombotic including alteplase are authorized if they follow the recommendations of the international guidelines. If alteplase infusion is given, no other anti-thrombotic drug is allowed for the following 24 hours. MT technique choice is left to the choice of the investigator.

Treatment:

Other: best medical management