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Acetazolamide Challenge With Perfusion in the Prediction of Cerebral Vasospasm

Primary Purpose

Subarachnoid Hemorrhage, Aneurysmal, Vasospasm, Cerebral

Status
Completed
Phase
Phase 4
Locations
United States
Study Type
Interventional
Intervention
Acetazolamide
Sponsored by
University of Wisconsin, Madison
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional diagnostic trial for Subarachnoid Hemorrhage, Aneurysmal focused on measuring acetazolamide challenge, cerebral vasospasm, aneurysmal subarachnoid hemorrhage

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  • Patients with aneurysmal subarachnoid hemorrhage presenting to our institution within 24 hours of symptom onset
  • Adults, 18 years of age or older
  • Women of childbearing potential must not be pregnant (negative urine pregnancy test)

Exclusion Criteria:

  • Contraindication to acetazolamide (i.e. sulfonamide allergy, renal or liver failure)
  • Contraindication to contrast media (Allergy or abnormal serum Cr and/or GFR based on current UW guidelines for IV contrast)
  • Renal insufficiency, history of renal failure or renal transplant
  • Hunt and Hess grade 1 and 5 (Attached protocol provides details on the grading scale. Grade 1 have lowest yield for vasospasm and Grade 5 are by definition critically ill and unstable patients)
  • Critically ill patients who are unstable and who cannot undergo scans within the proposed timeline i.e. within 24 hours of the onset of their symptoms.

Sites / Locations

  • University of Wisconsin

Arms of the Study

Arm 1

Arm Type

Experimental

Arm Label

Acetazolamide Challenge

Arm Description

Participants entered into the study as a cohort, will because of their participation, undergo only two additional digital subtraction angiogram (DSA) imaging acquisitions. These will be done in conjunction with their standard diagnostic DSA evaluation and consist of two CBCTPs, one before and one after administration of 1 g acetazolamide through a peripheral IV line. Each CBCTP will require administration of 75-100 mL iodinated contrast medium also through an intravenous line. Neither of these imaging studies will be used for clinical decision making, but would be processed and evaluated at later date for a formal analysis of the results. Following completion of diagnostic imaging subjects will receive the usual standard of care for treatment of their ruptured aneurysm i.e. endovascular embolization or open surgical clipping.

Outcomes

Primary Outcome Measures

Number of Participants Who Develop Delayed Cerebral Vasospasm
Clinical neurological deterioration not attributable to other causes, mores specifically not due to re-bleeding, hydrocephalus, or metabolic changes.

Secondary Outcome Measures

Relative Percent Change in Cerebral Blood Flow
The data that will be statistically compared is the pre-diamox perfusion in comparison to the post-diamox perfusion. A statistically significant change increase in CBF represents an appropriate response to Diamox. Lack of change in CBF or decrease in CBF could be suggestive of potential for developing vasospasm.
Percent Change in Left Hemisphere Brain Imaging Maps
Using perfusion map values, relative percent change will be calculated
Percent Change in Right Hemisphere Brain Imaging Maps
Using perfusion map values, relative percent change will be calculated

Full Information

First Posted
December 13, 2017
Last Updated
July 26, 2023
Sponsor
University of Wisconsin, Madison
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1. Study Identification

Unique Protocol Identification Number
NCT03377049
Brief Title
Acetazolamide Challenge With Perfusion in the Prediction of Cerebral Vasospasm
Official Title
C-arm Cone Beam CTA and CTP With Acetazolamide Challenge in Aneurysmal Subarachnoid Hemorrhage: Evaluating Predictability for Early Ischemia in Cerebral Vasospasm
Study Type
Interventional

2. Study Status

Record Verification Date
July 2023
Overall Recruitment Status
Completed
Study Start Date
July 28, 2019 (Actual)
Primary Completion Date
July 15, 2022 (Actual)
Study Completion Date
July 15, 2022 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
University of Wisconsin, Madison

4. Oversight

Studies a U.S. FDA-regulated Drug Product
Yes
Studies a U.S. FDA-regulated Device Product
No
Product Manufactured in and Exported from the U.S.
Yes

5. Study Description

Brief Summary
The investigators propose a technique using cone beam CT perfusion (CBCTP) imaging with an acetazolamide challenge as a potential diagnostic tool to detect a defect in cerebral autoregulation at a time when it has not yet caused clinically apparent signs or symptoms. 30 participants will be enrolled at the University of Wisconsin - Madison and can expect to be on study for about 2 weeks.
Detailed Description
Acetazolamide or vasodilatory challenge should identify subjects having a abnormal cerebrovascular reactivity capacity. More specifically, after receiving the drug there will not be the expected increase in cerebral blood flow (CBF) in some of the subjects because they are already suffering from a disturbance in the vasculature's ability to respond to the signal for vasodilation. The investigators believe the presence of this deficit will be helpful in identifying patients who are at risk for potential brain ischemia due to this decreased capacity to autoregulate if/when clinically significant vasospasm occurs. The investigators predict that acetazolamide-activated regional cerebral blood flow studies will be more sensitive in the detection of mild cerebral vasospasm and will not just detect changes in cerebral blood flow as does standard perfusion imaging, but will provide information regarding changes in cerebrovascular reactivity. Under these circumstances, a better predictor of those patients at risk of cerebral infarction due to delayed vasospasm would be delineated. Identifying this "high-risk cohort" prior to the onset of clinically apparent symptoms would result in the institution of preventative measures such as triple H therapy. The objective of this proposal is to conduct a feasibility study of acetazolamide activated C-arm cone beam CT perfusion (CBCTP) to determine its application in the prediction of symptomatic cerebral vasospasm (i.e. ischemia or stroke) in patients with aneurysmal subarachnoid hemorrhage. The initial plan is to obtain C-arm CBCTP pre- and post-intravenous infusion of 1g acetazolamide within 24 hours of symptom onset in aneurysmal subarachnoid hemorrhage patients. The hypothesis is that some of these patients that will later develop clinical vasospasm of a degree sufficient to cause cerebral ischemia. The investigators believe this cohort of patients will demonstrate altered cerebrovascular reactivity during the acetazolamide challenge at a time before there is either angiographic evidence of vasospasm or clinical evidence of abnormal perfusion.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Subarachnoid Hemorrhage, Aneurysmal, Vasospasm, Cerebral
Keywords
acetazolamide challenge, cerebral vasospasm, aneurysmal subarachnoid hemorrhage

7. Study Design

Primary Purpose
Diagnostic
Study Phase
Phase 4
Interventional Study Model
Single Group Assignment
Masking
None (Open Label)
Allocation
N/A
Enrollment
11 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Acetazolamide Challenge
Arm Type
Experimental
Arm Description
Participants entered into the study as a cohort, will because of their participation, undergo only two additional digital subtraction angiogram (DSA) imaging acquisitions. These will be done in conjunction with their standard diagnostic DSA evaluation and consist of two CBCTPs, one before and one after administration of 1 g acetazolamide through a peripheral IV line. Each CBCTP will require administration of 75-100 mL iodinated contrast medium also through an intravenous line. Neither of these imaging studies will be used for clinical decision making, but would be processed and evaluated at later date for a formal analysis of the results. Following completion of diagnostic imaging subjects will receive the usual standard of care for treatment of their ruptured aneurysm i.e. endovascular embolization or open surgical clipping.
Intervention Type
Drug
Intervention Name(s)
Acetazolamide
Other Intervention Name(s)
Diamox
Intervention Description
1 g acetazolamide through a peripheral IV line
Primary Outcome Measure Information:
Title
Number of Participants Who Develop Delayed Cerebral Vasospasm
Description
Clinical neurological deterioration not attributable to other causes, mores specifically not due to re-bleeding, hydrocephalus, or metabolic changes.
Time Frame
Day 1-14 during the hospitalization
Secondary Outcome Measure Information:
Title
Relative Percent Change in Cerebral Blood Flow
Description
The data that will be statistically compared is the pre-diamox perfusion in comparison to the post-diamox perfusion. A statistically significant change increase in CBF represents an appropriate response to Diamox. Lack of change in CBF or decrease in CBF could be suggestive of potential for developing vasospasm.
Time Frame
pre and post perfusion during imaging procedure, up to an hour
Title
Percent Change in Left Hemisphere Brain Imaging Maps
Description
Using perfusion map values, relative percent change will be calculated
Time Frame
pre and post perfusion during imaging procedure, up to an hour
Title
Percent Change in Right Hemisphere Brain Imaging Maps
Description
Using perfusion map values, relative percent change will be calculated
Time Frame
pre and post perfusion during imaging procedure, up to an hour

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: Patients with aneurysmal subarachnoid hemorrhage presenting to our institution within 24 hours of symptom onset Adults, 18 years of age or older Women of childbearing potential must not be pregnant (negative urine pregnancy test) Exclusion Criteria: Contraindication to acetazolamide (i.e. sulfonamide allergy, renal or liver failure) Contraindication to contrast media (Allergy or abnormal serum Cr and/or GFR based on current UW guidelines for IV contrast) Renal insufficiency, history of renal failure or renal transplant Hunt and Hess grade 1 and 5 (Attached protocol provides details on the grading scale. Grade 1 have lowest yield for vasospasm and Grade 5 are by definition critically ill and unstable patients) Critically ill patients who are unstable and who cannot undergo scans within the proposed timeline i.e. within 24 hours of the onset of their symptoms.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Azam Ahmed, MD
Organizational Affiliation
University of Wisconsin, Madison
Official's Role
Principal Investigator
Facility Information:
Facility Name
University of Wisconsin
City
Madison
State/Province
Wisconsin
ZIP/Postal Code
53792
Country
United States

12. IPD Sharing Statement

Plan to Share IPD
No
Citations:
PubMed Identifier
1858527
Citation
Shinoda J, Kimura T, Funakoshi T, Araki Y, Imao Y. Acetazolamide reactivity on cerebral blood flow in patients with subarachnoid haemorrhage. Acta Neurochir (Wien). 1991;109(3-4):102-8. doi: 10.1007/BF01403003.
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9861845
Citation
Tanaka A, Yoshinaga S, Nakayama Y, Tomonaga M. Cerebral blood flow and the response to acetazolamide during the acute, subacute, and chronic stages of aneurysmal subarachnoid hemorrhage. Neurol Med Chir (Tokyo). 1998 Oct;38(10):623-30; discussion 630-2. doi: 10.2176/nmc.38.623.
Results Reference
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PubMed Identifier
16498198
Citation
Lee KH, Lukovits T, Friedman JA. "Triple-H" therapy for cerebral vasospasm following subarachnoid hemorrhage. Neurocrit Care. 2006;4(1):68-76. doi: 10.1385/NCC:4:1:068.
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Results Reference
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PubMed Identifier
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Citation
Sullivan HG, Kingsbury TB 4th, Morgan ME, Jeffcoat RD, Allison JD, Goode JJ, McDonnell DE. The rCBF response to Diamox in normal subjects and cerebrovascular disease patients. J Neurosurg. 1987 Oct;67(4):525-34. doi: 10.3171/jns.1987.67.4.0525.
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Hauge A, Nicolaysen G, Thoresen M. Acute effects of acetazolamide on cerebral blood flow in man. Acta Physiol Scand. 1983 Feb;117(2):233-9. doi: 10.1111/j.1748-1716.1983.tb07202.x.
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Citation
Kimura T, Shinoda J, Funakoshi T. Prediction of cerebral infarction due to vasospasm following aneurysmal subarachnoid haemorrhage using acetazolamide-activated 123I-IMP SPECT. Acta Neurochir (Wien). 1993;123(3-4):125-8. doi: 10.1007/BF01401867.
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Acetazolamide Challenge With Perfusion in the Prediction of Cerebral Vasospasm

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