Abstract
The 1990s have been designated as the “Decade of the Brain.” In a position statement, the National Advisory Neurological Disorders and Stroke Council (1990) stated that during this period we will see “The prevention of 80% of all strokes and protection of the brain during the acute stroke.” To accomplish this task new therapies must be developed. The safety and efficacy of any new agent must be demonstrated in adequate and well-controlled trials. The fact that there are no effective agents in the area of stroke treatment prevents us from having a standard to which new agents can be compared. Without a baseline it becomes difficult to select the proper dosage, determine the maximum treatment duration, and choose the proper measurements in order to assess the efficacy of a new agent. There have been numerous agents tested over the past decade. Unfortunately there is still no consensus among stroke investigators as to the ideal protocol design. A critical review of past studies can help determine strategies for a successful development program of future drugs. It is hoped that this review can encourage the development of adequate and well-controlled protocols that will fulfill the U.S. Food and Drug Administration’s (FDA’s) requirements.
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References
Abe K, Kogure K, Watanabe T (1988): Prevention of ischemic and postischemic brain edema by a novel calcium antagonist (PN 200–110). J Cereb Blood Flow Metab 8: 436–439
Abramson NS, Meisel A, Safar P (1986): Deferred consent: A new approach for resuscitation research on comatose patients JAMA 255: 2466–2471
Adams HP Jr, Olinger CP, Barsan WG, Butler MJ, Graff-Radford NR, Brott TG, Biller J, Damasio H, Tomsick T, Goldberg M, Spilker JA, Berlinger E, Dambrosia J, Biros M, Hollern R (1986): A dose-escalation study of large doses of naloxone for treatment of patients with acute cerebral ischemia. Stroke 17: 404–409
Adams RJ, Meador KJ, Sethi KD, Grotta JC, Thomson DS (1987): Graded neurologic scale for use in acute hemispheric stroke treatment protocols. Stroke 18: 665–669
Adams RJ, Nichols FT, Thompsom WO (1989): Neurological assessment in acute stroke. Issues in the use of rating scales. In: Clinical Trial Methodology in Stroke, Amery WK, Bousser M-G, Clifford Rose F, eds. London: Bailliere Tindall
Barer DH, Ebrahim SB, Mitchell JRA (1988): The pragmatic approach to stroke trial design: Stroke register, pilot trial, assessment of neurological then functional outcome. Neuroepidemiology 7: 1–12
Barsan WG, Brott TG, Olinger CP, Adams HP Jr, Haley EC Jr, Levy DE (1988): Identification and entry of the patient with acute cerebral infarction. Ann Emerg Med 17: 1192–1195
Barsan WG, Brott TG, Olinger CP, Marler JR (1989): Early treatment for acute ischemic stroke. Ann Intern Med 111: 449–451
Bayer AJ, Pathy MSJ, Newcombe R (1987): Double-blind randomized trial of intravenous glycerol in acute stroke. Lancet i:405–407
Bielenberg GW, Burkhardt M (1990): 5–Hydroxytryptamine, A agonists. A new therapeutic principle for stroke treatment. Stroke 21 (Suppl IV):IV161–IV163
Biller J, Love BB, Marsh EE III, Jone MP, Knepper LE, Jiang D, Adams HP Jr, Gordon DL (1990) Spontaneous improvement after acute ischemic stroke: A pilot study. Stroke 21: 1008–1012
Biller J, Massey EW, Marler JR, Adams HP, Davis JN, Bruno A, Henriksen RA, Linhardt RJ, Goldstein LB, Alberts M, Kisker CT, Toffol GJ, Greenberg CS, Ganwart KJ, Bertels C, Beck DW, Walker M, Magnani HN (1989): A dose escalation study of ORG 10172 (low molecular weight heparinoid) in stroke. Neurology 39: 262–265
Bogousslaysky J, Regli F, Zumstein V, Kobberling W (1990): Double-blind study of nimodipine in non-severe stroke. Eur Neurol 30: 23–26
Britton M, Roden A (1986): Progression of stroke after arrival at hospital. Stroke 16: 629–632
Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V, Rorick M, Moomaw CJ, Walker M (1989): Measurements of acute cerebral infarction: A clinical examination scale. Stroke 20: 864–870
Brott TG, Haley EC, Levy DE, Barsan WG, Reed RL, Olinger CP, Marler JR (1988): Tissue plasminogen activator (tPA) as very early therapy for cerebral infarction. Stroke 19: 133
Brott TG, Haley EC, Levy DE, Barsan W, Sheppard G, Broderick J, Reed R, Marler J (1990): Safety and potential efficacy of tissue plasminogen activator (tPA) for stroke. Stroke 21: 27
Buchan AM, Xue D, Slivka A (1990): MK-801 reduces the volume of neocortical infarction but also increases regional cerebral blood flow. Stroke 21: 9
Capildeo R, Haberman S, Rose FC (1982): Stroke trials: The facts. Advan Stroke Ther 16: 413–416
Candelise L (1989): Clinical trial methodology in stroke. Multicentre studies: Keep the protocol simple. In: Clinical Trial Methodology in Stroke, Amery WK, Bousser MG, Clifford Rose F, eds, London: Bailliere Tindall
Cooper A (1836): Some experiments and observations on tying the carotid and vertebral arteries. Guys Hosp Rep 1: 458–475
Cote R, Battista RN, Wolfson M, Hachinski VC (1988): Stroke assessment scales: Guidelines for development, validation, and reliability assessment. Can J Neurol Sci 15: 261–265
Cote R, Battista RN, Wolfson M, Boucher J, Adam J, Hachinski VC (1989): The Canadian Neurological Scale: Validation and reliability assessment. Neurology 39: 638–643
Cote R, Hachinski VC, Shurvell BL, Norris JW, Wolfson C (1986): The Canadian
Neurological Scale: A preliminary study in acute stroke. Stroke 17: 731–737
Czionkowska A, Cyrta B (1988): Effects of naloxone on acute stroke. Pharmacopsychiatry 21: 98–100
Davalos A, Cendra E, Teruel J, Martinez M, Genis D (1990): Deteriorating ischemic stroke: Risk factors and prognosis. Neurology 40: 1865–1869
del Zuppo GJ (1990): An open, multicenter trial of recombinant tissue plasminogen activator in acute stroke. A progress report. Stroke 21 (Suppl IV):IV174–IV175
Duncan PW, Propst M, Nelson SG (1983): Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther 63: 1606–1610
Frei A, Cottier C, Wunderlich P (1987): Glycerol and dextran combined in the therapy of acute stroke. A placebo-controlled, double-blind trial with a planned interim analysis. Stroke 18: 373–379
Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S (1975): The post-stroke hemiplegic patient. I. A method for evaluation of physical performance. Scand J Rehabil Med 14: 27–32
Gelmers HJ (1984): The effects of nimodipine on the clinical course of patients with acute ischemic stroke. Acta Neurol Scand 69: 232–239
Gelmers HJ, Hennerici M (1990): Effect of nimodipine on acute ischemic stroke. Pooled results from five randomized trials. Stroke 21 (Suppl IV):IV81–IV84
Gelmers HJ, Gorter K, de Weerdt CJ, Wiezer HJA (1988): A controlled trial of nimodipine in acute ischemic stroke. N Engl J Med 318: 203–207
Giraldi C, Masi MC, Manetti M, Carabelli E, Martini A (1990): A pilot study with monosialoganglioside GM1 on acute cerebral ischemia. Inst Clin Neurol Pisa Univ 214–221
Goldstein LB, Bertels C, Davis JN (1989): Interrater reliability of the NIH stroke scale. Arch Neurol 46: 660–662
Gowland CA (1990): Staging motor impairment after stroke. Stroke 21 (Suppl II):II19–1I21
Grotta JC, Rosenbaum D, Zabramski J, Picone C, Pettigrew LC, Marier J, Ellis D, Bratina P, Lopez L, Spetzler R (1988): Pilot study of nicardipine (NC) for acute stroke (abstract). Neurology 38 (Suppl 1): 109
Grotta JC, Picone CM, Yao L (1990): CGS 19755 reduces calcium-calmodulin binding after cerebral ischemia. Stroke 21: 7
Hachinski V (1990): Classification of stroke for clinical trials. Stroke 21 (Suppl II): I127–1129
Hsu CY, Faught RE Jr, Furlan AJ, Coull BM, Huang DC, Hogan EL, Linet OI, Yatsu FM (1987): Intravenous prostacyclin in acute nonhemorrhagic stroke: A placebo-controlled double-blind trial. Stroke 18: 352–358
Hsu CY, Norris JW, Hogan EL (1988): Pentoxifylline in acute nonhemorrhagic stroke. A randomized, placebo-controlled, double-blind trial. Stroke 19: 716–722
Hulser PJ, Bernhart H, Marbach C, Kornhuber HH (1988): Treatment with an i.v. calcium overload blocker (flunarizine) in acute stroke. A pilot study. Eur Arch Psychiatr Neurol Sci 237: 253–257
Hulser PJ, Kornhuber AW, Kornhuber HH (1990): Treatment of Acute Stroke with Calcium Antagonists, Eur Neurol 30 (Suppl 2): 25–38
Kramer G, Tettenborn B, Rothacker G, Hacke W, Busse O, Hornig CR, Aichner F, Ladurner G (1990): Nimodipine German-Austrian stroke trial (abstract). Neurology 40 (Suppl I): 415–416
LaRue LJ, Alter M, Traven ND (1988): Acute stroke therapy trials: Problems in patient accrual. Stroke 19: 950–954
Limburg M, Hijdra A (1990): Flunarizine in acute ischemic stroke: A pilot study. Eur Neurol 30: 121–122
Lin B, Dietrich D, Busto R, Ginsberg MD (1990): (s)-Emopamil protects against global ischemic injury in rats. Stroke 21: 1734–1739
Loewen SC, Anderson BA (1988): Reliability of the modified motor assessment scale and the Barthel index. Phys Ther 68: 1077–1081
Mahoney FI, Barthel DW (1965): Functional evaluation. The Barthel index. Md State Med J 14: 61–65
Martin JF, Handy N, Nicholl J, Lewtas N, Bergvall U, Owen P, Syder D, Holroyd M (1985): Double-blind controlled trial of prostacyclin in cerebral infarction. Stroke 16: 386–390
Martinez-Vila E, Guillen F, Villanueva JA, Matias-Guiru J, Bigorra J, Gil P, Carbonell A, Martinez-Lage JM (1990): Placebo-controlled trial of nimodipine in the treatment of acute ischemic cerebral infarction. Stroke 21: 1023–1028
Massey EW, Biller J, Davis JN, Adams HP Jr, Marler JR, Goldstein LB, Alberts M, Bruno A (1990): Large-dose infusions of heparinoid ORG 10172 in ischemic stroke. Stroke 21: 1289–1292
Mathew NT, Meyer JS, Rivera VH, Charney JZ, Hartmann A (1972): Double-blind evaluation of glycerol treatment in acute cerebral infarction. Lancet ii: 1327–1329
Mohr JP, Dijanni M, Muschett JL, Riccio RV, GH Besselaar Associates, Nimodipine Study Group (1989): Nimodipine in acute ischemic stroke. Ann Neurol 26: 124
Molinari GF (1988): Why model strokes? Stroke 19: 1195–1197
Nakayama H, Ginsberg MD, Dietrich, WD (1988): (s)-Emopamil, a novel calcium channel blocker and serotonin SZ antagonist, markedly reduces infarct size following middle cerebral artery occlusion in the rat. Neurology 38: 1667–1673
National Advisory Neurological Disorders and Stroke Council (1990): Implementation plan for the decade of the brain. Executive Summary. Neurology 40: 1483–1486
Norris JW (1983) Comment on “Study design of stroke treatments” (letter). Stroke 13: 527–528
Oczkowski WJ, Hachinski VC, Bogousslaysky J, Barnett HJM, Carruthers SG (1989): A double-blind, randomized trial of PY108–068 in acute ischemic cerebral infarction. Stroke 20: 604–608
Olesen J, Simonsen K, Norgaard B (1988) Reproducibility and utility of a simple neurological scoring system for stroke patients (Copenhagen stroke scale). J Neurol Rehab 2: 59–63
Olinger CP, Adams HP Jr, Brott TG, Biller J, Barsan WG, Toffol GJ, Eberle RW, Marler JR (1990): High-dose intravenous naloxone for the treatment of acute ischemic stroke. Stroke 21: 721–725
Orgogozo JM (1989): Evaluation of treatments in ischemic-stroke patients. In: Clinical Trial Methodology in Stroke, Amery WK, Bousser M-G, Clifford Rose F, eds, London: Bailliere Tindall
Orgogozo JM, Capildeo R, Anagnostou CN (1983): Mise au point d’un score neurologigue pour l’évaluation cliniques des infarctus sylviens. Nouv Presse Med 12: 3039–3044
Orgogozo JM, Dartigues JF (1986): Clinical trials in acute brain infarction. The question of assessment criteria. In: Acute Brain Ischemia, Battistini N et al., eds. New York: Raven Press
Oxbury JM, Greenhall RCD, Grainger KMR (1975): Predicting the outcome of stroke: Acute stage after cerebral infarction. Br Med J 3: 125–127
Paci A, Ottaviano P, Trenta A, Iannone G, De Santis L, Lancia G, Moschini E, Carosi M, Amigoni S, Caresia L (1989): Nimodipine in acute ischemic stroke: a double-blind controlled study. Acta Neurol Scand 80: 282–286
Parkinson Study Group (1989): Effect of deprenyl (selegiline) on the progression of disability in early Parkinson’s disease. N Engl J Med 321 (20): 1364–1371
Patten BM, Mendell J, Bruun B, Curtin W, Carter S (1972): Double-blind study of the effects of dexamethasone on acute stroke. Neurology 22: 377–383
Pulsinelli WA, Buchan A (1989): The utility of animal ischemia models in predicting pharmacotherapeutic response in the clinical setting. In: Cerebrovascular Diseases, Ginsberg MD, Dietrich WD, eds. New York: Raven Press
Rosenbaum DM, Grotta JC, Yatsu FM, Picone CM, Pettigrew LC, Bratina P, Zabramski J, Spetzler R, Lopez L, Marler J, Ellis D (1990): Pilot study of nicardipine for acute ischemic stroke. Angiology-T J Vasc Dis 1017–1022
Rosenbaum DM, Zabramski J, Frey J, Yatsu F, Marler J, Spetzler R, Grotta J (1991): Early treatment of ischemic stroke with a calcium antagonist. Stroke 22: 437–441
Sauter A, Rudin M (1990): Calcium antagonists for reduction of brain damage in stroke. J Cardiovasc Pharmacol 15 (Suppl 1): S43–S47
Spence JD, Donner A (1982): Problems in design of stroke treatment trials. Stroke 13: 94–99
Steiner TJ, Clifford Rose F (1986a): Randomized double-blind placebo-controlled clinical trial of naftidrofuryl in hemiparetic CT-proven acute cerebral hemisphere infarction. R Soc Med Int Congr Symp Ser 99: 85–98
Steiner TJ, Clifford Rose F (1986b): Towards a model stroke trial. The single-centre naftidrofuryl study. Neuroepidemiology 5: 121–147
Sterman AB, Furlan AJ, Pessin P, Kase C, Caplan L, Williams G (1987): Acute stroke therapy trials: An introduction to recurring design issues. Stroke 18: 524–527
Sundt TM Jr, Grant WC, Garcia JH (1969): Restoration of middle cerebral artery flow in experimental infarction. J Neurosurg 31: 311–321
Tmerding BL, Barsan WG, Hedges JR, Brott TG, VanLigten PF, Spilker JA, Olinger CP (1989): Stroke patient evaluation in the emergency department before pharmacologic therapy. Am J Emerg Med 7:11–15
TRUST Study Group (1990): Randomised, double-blind, placebo controlled trial of nimodipine in acute stroke. Lancet 336: 1205–1209
Tuthill JE, Pozen TJ, Kennedy FB (1969): A neurologic grading system for acute stroke. Am Heart J 78: 53–57
Uematsu D, Araki N, Greenberg JH, Sladky J, Reivich M (1991): Combined therapy with MK-801 and nimodipine for protection of ischemic brain damage. Neurology 41: 88–94
Walker AE, Robins M, Weinfeld FD (1981): The national survey of stroke. 3. Clinical findings. Stroke 12: 113–131
Whisnant JP, Basford JR, Bernstein EF, Cooper ES, Dyken ML, Easton D, Little JR, Marler JR, Millikaan CH, Petito CK, Price TR, Raichle ME, Robertson JT, Thiele B, Walker MD, Zimmerman RA (1990): Classification of cerebrovascular diseases III. Stroke 21: 637–676
Wiebers DO, Adams Jr HP, Whisnant JP (1990): Animal models of stroke: Are they relevant to human disease? Stroke 21: 1–3
Wood-Dauphinee SL, Ivan Williams J, Shapiro SH (1990): Examining outcome measures in a clinical study of stroke. Stroke 21: 731–739
Xue D, Bruederlin B, Heinicke E, Li H, Slivka A, Buchan A (1990): U74006U reduces neocortical infarction but does not attenuate selective hippocampal CA1 neurons. Stroke 21: 24
Yatsu FM, Becker C, McLeroy KR, Coull B, Feibel J, Howard G, Toole JF, Walker MD (1986): Community hospital-based stroke programs: North Carolina, Oregon, and New York. I. Goals, objectives, and data collection procedures. Stroke 17: 276–284
Zivin JA, Grotta JC (1990): Animal stroke models: They are relevant to human disease. Stroke 21: 981–983
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Meibach, R.C. (1992). Clinical Trial Issues in Stroke Therapy. In: Marangos, P.J., Lal, H. (eds) Emerging Strategies in Neuroprotection. Advances in Neuroprotection, vol 22. Birkhäuser, Boston, MA. https://doi.org/10.1007/978-1-4684-6796-3_16
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