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Study on Tirofiban With Aspirin in the Treatment of Acute Penetrating Artery Territory Infarction (STRATEGY)

Primary Purpose

Branch Atheromatous Disease

Status
Recruiting
Phase
Phase 4
Locations
China
Study Type
Interventional
Intervention
Tirofiban hydrochloride sodium chloride injection
Tirofiban hydrochloride sodium chloride injection placebo
Aspirin
Sponsored by
Beijing Tiantan Hospital
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional treatment trial for Branch Atheromatous Disease focused on measuring branch atheromatous disease, perforating artery territorial infarction, tirofiban, aspirin, randomized controlled trial, multicenter study, double blind study, placebo-controlled

Eligibility Criteria

18 Years - 80 Years (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion Criteria:

  1. 18-80 years old;
  2. No gender limitation;
  3. Within 48 hours of onset;
  4. Clinical symptoms and signs suggest acute single infarction of penetrating artery territory (no cortical involvement, no multifocal involvement, NIHSS ≤10 and consciousness-1a ≤1);
  5. DWI suggests single infarction (diameter < 30mm) of penetrating artery territory (basal ganglia, internal capsule, thalamus, pons, etc.), which involves at least 2 axial layers, or its maximum diameter ≥15mm, or it is connected to the ventral surface of the pons, closing to but not crossing the midline, and located in one side;
  6. No severe stenosis (defined as > 70%) of parent artery giving off the responsible penetrating artery;
  7. The patient or his / her legal representative is able and willing to sign the informed consent.

Exclusion Criteria:

  1. History of intracranial hemorrhage (subarachnoid hemorrhage and cerebral hemorrhage);
  2. History of intracranial tumors, cerebral arteriovenous malformation, or aneurysm;
  3. Emergency endovascular intervention or intravenous thrombolysis before randomization;
  4. Dual antiplatelet therapy currently or within 14 days of randomization (excluding use of aspirin and clopidogrel after onset without loading dose of clopidogrel);
  5. Use of other antiplatelet drugs (ticagrelor, cilostazol, etc.), anticoagulant drugs, snake venom, defibrase, lumbrukinase or other defibrase treatments after onset;
  6. Expected long-term use of non-investigational antiplatelet drugs or non-steroidal anti-inflammatory drugs;
  7. With severe stenosis (> 70%) of parent artery giving off responsible penetrating artery;
  8. Definite indications for anticoagulation (suspicion of cardioembolism, e.g. atrial fibrillation, known heart valve prosthesis, atrial myxoma, endocarditis, etc.) or definite indications for dual antiplatelet therapy (e.g. recent coronary or cerebral artery stent implantation);
  9. Severe hepatic or renal insufficiency before randomization (severe hepatic insufficiency refers to ALT or AST > 3 times the upper limit of normal; severe renal insufficiency refers to creatinine clearance rate (CCr) < 30ml/min);
  10. Hemorrhagic tendency (including but not limited to):PLT<100×109/L; heparin treatment within 48h; APTT ≥ 35s; current use of warfarin, INR > 1.7; current use of novel oral anticoagulants; current use of direct thrombin or factor Xa inhibitor;
  11. Resistant hypertension which could not be controlled by medicine (SBP > 180mmHg or DBP > 110mmHg);
  12. History of obvious head trauma or stroke within three months of randomization;
  13. History of intracranial or intramedullary surgery within three months of randomization;
  14. History of major surgery or severe physical trauma within one month of randomization;
  15. Severe neurological defects (mRS ≥ 2) before the onset;
  16. Acute pericarditis;
  17. Hemorrhagic retinopathy;
  18. Childbearing-age women who do not take effective methods of contraception without negative records of pregnancy tests;
  19. Known to be allergic to tirofiban;
  20. Other surgical or interventional therapy planned within 3 months requiring experimental drugs discontinuation;
  21. Life expectancy < 6 months due to any terminal illness;
  22. Patients who are undergoing experimental drugs or instruments;
  23. Other conditions which suggest participants are unsuitable for this study, e.g. inability for understanding and / or obeying research procedures and / or follow-up due to mental diseases, cognitive or mood disturbance, or with MRI contraindications, etc.

Sites / Locations

  • Beijing HospitalRecruiting
  • The Affiliated Dongnan Hospital of Xiamen UniversityRecruiting
  • Hejian People's HospitalRecruiting
  • The People's Hospital of Qinghe CountyRecruiting
  • Mengzhou People's HospitalRecruiting
  • The People's Hospital of Xiuwu CountyRecruiting
  • Traditional Chinese Medicine Hospital of Jiyuan CityRecruiting
  • The First People's Hospital of NanyangRecruiting
  • The People's Hospital of Tanghe CountyRecruiting
  • Traditional Chinese Medicine Hospital of Sui CountyRecruiting
  • The People's Hospital of Biyang CountyRecruiting
  • Shaodong People's HospitalRecruiting
  • The Third People's Hospital of Tongzhou District, Nantong CityRecruiting
  • The First People's Hospital of XianyangRecruiting
  • Liaocheng Central HospitalRecruiting
  • The People's Hospital of Guan CountyRecruiting
  • The Third People's Hospital of LiaochengRecruiting
  • Weihai Wendeng District People's HospitalRecruiting
  • Changzhi People's HospitalRecruiting
  • The People's Hospital of Wanrong CountyRecruiting

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Placebo Comparator

Arm Label

Tirofiban group

Tirofiban placebo group

Arm Description

This group will receive tirofiban and aspirin. Day 1: Tirofiban injected intravenously for 24 hours and aspirin of 100-300 mg. Tirofiban will be injected at 4 ug/kg/ min for the first 30 minutes and 0.1 ug/kg/min for the next 24 hours. Day 2-90: Aspirin 100mg per day.

This group will receive tirofiban placebo and aspirin. Day 1: Tirofiban placebo injected intravenously for 24 hours and aspirin of 100-300 mg. The placebo will be injected at the same rate with Tirofiban group. Day 2-90: Aspirin 100mg per day.

Outcomes

Primary Outcome Measures

Number of participants with new stroke
Symptoms and signs of acute neurological deficits caused by sudden focal or whole brain, spinal cord, or retinal vascular damage, which are related to cerebral circulatory disorders, including hemorrhagic and ischemic stroke.
Number of participants with early progression of stroke
NIHSS score increasing by ≥ 2 points, or the score of hemiplegia increasing by≥1 point, or the score of conscious disturbance increasing by ≥ 1 point compared with baseline within 7 days of onset, and intracranial hemorrhage is excepted by CT or MRI. Exacerbations not attributable to stroke are also excluded such as cardiac failure, liver and renal failure, etc.

Secondary Outcome Measures

Number of participants with new stroke or stroke progression
Hemorrhagic and ischemic stroke; NIHSS score increasing by ≥ 2 points, or the score of hemiplegia increasing by≥1 point, or the score of conscious disturbance increasing by ≥ 1 point compared with baseline within 7 days of onset.
Number of participants with composite vascular events
Symptomatic stroke, myocardial infarction and vascular death.
Number of participants with disability or death
The modified Rankin Scale (mRS) is 2-6 points.
Number of participants with improvement of neurological function
NIHSS score increasing by ≥ 4 points or increasing to 0-1 points compared with baseline.
EuroQol five dimensions questionnaire (EQ-5D)
It includes a descriptive system(DS) and a visual analogue scale(VAS). Two indicators are index value(ranged 0-1) and visual score(ranged 0-100) with higher scores corresponding to better health status.

Full Information

First Posted
March 27, 2022
Last Updated
November 4, 2022
Sponsor
Beijing Tiantan Hospital
Collaborators
GrandPharma (China) Co., Ltd.
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1. Study Identification

Unique Protocol Identification Number
NCT05310968
Brief Title
Study on Tirofiban With Aspirin in the Treatment of Acute Penetrating Artery Territory Infarction
Acronym
STRATEGY
Official Title
Study on Tirofiban With Aspirin in the Treatment of Acute Penetrating Artery Territory Infarction: A Randomized, Double-blinded, Placebo-controlled, Multi-center Trial
Study Type
Interventional

2. Study Status

Record Verification Date
November 2022
Overall Recruitment Status
Recruiting
Study Start Date
November 2022 (Anticipated)
Primary Completion Date
June 2024 (Anticipated)
Study Completion Date
September 2024 (Anticipated)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Principal Investigator
Name of the Sponsor
Beijing Tiantan Hospital
Collaborators
GrandPharma (China) Co., Ltd.

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
No
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
Perforating artery territorial infarction (PAI) refers to a single ischaemic lesion <20 mm in a single perforating arterial territory and branch atheromatous disease (BAD) is a important etiological factor. BAD related infarction accounts for 10%-15% ischemic cerebral infarction and is closely related to early neurological deterioration (END). Among patients with BAD, dual antiplatelet (clopidogrel plus aspirin) did not significantly reduce the risk of recurrent stroke. The primary purpose of this study is to assess the efficacy and safety of tirofiban combined with aspirin versus placebo combined with aspirin in reducing the risk of recurrence and progression of stroke at 90 days in patients with acute penetrating artery territory infarction.
Detailed Description
Perforating artery territorial infarction (PAI) constitute about 25% of ischemic strokes, including three pathophysiological mechanisms - lipohyalinosis, microatheroma and large parent artery plaque. The latter two are prone to stroke recurrence and early neurological deterioration. Aspirin plus clopidogrel are effective antiplatelet therapy for PAI patients with parent artery stenosis, but controversial in patients with branch atheromatous disease (BAD). Early rapid initiation of platelet aggregation inhibitors, such as Tirofiban, a GPIIb/IIIa receptor antagonist, may benefit those patients. The primary purpose of this study is to assess the efficacy and safety of tirofiban combined with aspirin versus placebo combined with aspirin in reducing the risk of recurrence and progression of stroke at 90 days in patients with acute penetrating artery territory infarction caused by BAD. This is a prospective, randomized, multicenter, double-blind clinical trial. In 40 centers in China, 970 patients with the following situations will be enrolled: single acute infarction of penetrating artery territory within 48 hours of onset, which involves at least 2 axial layers, or whose maximum diameter ≥15mm, or connected to the ventral surface of the median pons without crossing the midline on DWI image, no severe stenosis (defined as > 70%) of parent artery. Patients will be randomly assigned into 2 groups according to the ratio of 1:1: Tirofiban (Day 1) + Aspirin (Day 1-90) Placebo (Day 1) + Aspirin (Day 1-90) Face to face interviews will be made on baseline, 24 hours after randomization, day 7 after randomization, discharge day, and day 90 after randomization. Survival curves will be estimated for the primary outcome using the Kaplan-Meier procedure and compared using a Cox regression model Wald test, stratified by the opposite arm of the factorial design. Safety outcomes will be calculated using the Kaplan-Meier curve to simulate the 3-month cumulative risk, and the Cox proportional hazards model to calculate the HR and 95% confidence interval. The primary endpoints include recurrent stroke and early progression of stroke. The secondary endpoints include composite vascular events (stroke, myocardial infarction, and cardiovascular death), disability or death (mRS 2-6), improvement of neurological function and EQ-5D score. The safety endpoints include severe hemorrhage events, symptomatic and non-symptomatic intracranial hemorrhage, moderate hemorrhage, vascular death, overall mortality and (serious) adverse event.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Branch Atheromatous Disease
Keywords
branch atheromatous disease, perforating artery territorial infarction, tirofiban, aspirin, randomized controlled trial, multicenter study, double blind study, placebo-controlled

7. Study Design

Primary Purpose
Treatment
Study Phase
Phase 4
Interventional Study Model
Parallel Assignment
Masking
ParticipantCare ProviderInvestigatorOutcomes Assessor
Allocation
Randomized
Enrollment
970 (Anticipated)

8. Arms, Groups, and Interventions

Arm Title
Tirofiban group
Arm Type
Experimental
Arm Description
This group will receive tirofiban and aspirin. Day 1: Tirofiban injected intravenously for 24 hours and aspirin of 100-300 mg. Tirofiban will be injected at 4 ug/kg/ min for the first 30 minutes and 0.1 ug/kg/min for the next 24 hours. Day 2-90: Aspirin 100mg per day.
Arm Title
Tirofiban placebo group
Arm Type
Placebo Comparator
Arm Description
This group will receive tirofiban placebo and aspirin. Day 1: Tirofiban placebo injected intravenously for 24 hours and aspirin of 100-300 mg. The placebo will be injected at the same rate with Tirofiban group. Day 2-90: Aspirin 100mg per day.
Intervention Type
Drug
Intervention Name(s)
Tirofiban hydrochloride sodium chloride injection
Intervention Description
Day 1: Tirofiban will be given by bolus injection at 0.4ug/kg/min for the first 30 minutes, followed by a continuous infusion at 0.1ug/kg/min for the next 24 hours.
Intervention Type
Drug
Intervention Name(s)
Tirofiban hydrochloride sodium chloride injection placebo
Intervention Description
Day 1: Tirofiban placebo will be injected at the same rate with experimental group.
Intervention Type
Drug
Intervention Name(s)
Aspirin
Intervention Description
Day 1: Aspirin 100-300mg per day Day 2-90: Aspirin 100mg per day
Primary Outcome Measure Information:
Title
Number of participants with new stroke
Description
Symptoms and signs of acute neurological deficits caused by sudden focal or whole brain, spinal cord, or retinal vascular damage, which are related to cerebral circulatory disorders, including hemorrhagic and ischemic stroke.
Time Frame
90 days after randomization
Title
Number of participants with early progression of stroke
Description
NIHSS score increasing by ≥ 2 points, or the score of hemiplegia increasing by≥1 point, or the score of conscious disturbance increasing by ≥ 1 point compared with baseline within 7 days of onset, and intracranial hemorrhage is excepted by CT or MRI. Exacerbations not attributable to stroke are also excluded such as cardiac failure, liver and renal failure, etc.
Time Frame
7 days after randomization
Secondary Outcome Measure Information:
Title
Number of participants with new stroke or stroke progression
Description
Hemorrhagic and ischemic stroke; NIHSS score increasing by ≥ 2 points, or the score of hemiplegia increasing by≥1 point, or the score of conscious disturbance increasing by ≥ 1 point compared with baseline within 7 days of onset.
Time Frame
24 hours and 7 days after randomization
Title
Number of participants with composite vascular events
Description
Symptomatic stroke, myocardial infarction and vascular death.
Time Frame
90 days after randomization
Title
Number of participants with disability or death
Description
The modified Rankin Scale (mRS) is 2-6 points.
Time Frame
90 days after randomization
Title
Number of participants with improvement of neurological function
Description
NIHSS score increasing by ≥ 4 points or increasing to 0-1 points compared with baseline.
Time Frame
24 hours, 7 days, and 90 days after randomization
Title
EuroQol five dimensions questionnaire (EQ-5D)
Description
It includes a descriptive system(DS) and a visual analogue scale(VAS). Two indicators are index value(ranged 0-1) and visual score(ranged 0-100) with higher scores corresponding to better health status.
Time Frame
90 days after randomization
Other Pre-specified Outcome Measures:
Title
Number of participants with severe hemorrhage events
Description
Fatal hemorrhage or symptomatic intracranial hemorrhage.
Time Frame
90 days after randomization
Title
Number of participants with symptomatic intracranial hemorrhage
Description
According to Heidelberg Bleeding Classification.
Time Frame
90 days after randomization
Title
Number of participants with symptomatic and non-symptomatic intracranial hemorrhage
Description
According to Heidelberg Bleeding Classification.
Time Frame
90 days after randomization
Title
Number of participants with moderate hemorrhage events
Description
In need of blood transfusion without hemodynamic changes requiring interventions.
Time Frame
90 days after randomization
Title
Number of participants with vascular death
Description
Stroke, myocardial infarction, peripheral arterial ischemia, pulmonary embolism, ruptured abdominal aortic aneurysm, and systemic bleeding.
Time Frame
90 days after randomization
Title
Overall mortality
Description
The ratio of total deaths from all causes to the research subjects
Time Frame
90 days after randomization
Title
Number of participants with dverse event/serious adverse event
Description
PLT≤100×109/L; hypersensitivity; renal failure
Time Frame
90 days after randomization

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Maximum Age & Unit of Time
80 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion Criteria: 18-80 years old; No gender limitation; Within 48 hours of onset; Clinical symptoms and signs suggest acute single infarction of penetrating artery territory (no cortical involvement, no multifocal involvement, NIHSS ≤10 and consciousness-1a ≤1); DWI suggests single infarction (diameter < 30mm) of penetrating artery territory (basal ganglia, internal capsule, thalamus, pons, etc.), which involves at least 2 axial layers, or its maximum diameter ≥15mm, or it is connected to the ventral surface of the pons, closing to but not crossing the midline, and located in one side; No severe stenosis (defined as > 70%) of parent artery giving off the responsible penetrating artery; The patient or his / her legal representative is able and willing to sign the informed consent. Exclusion Criteria: History of intracranial hemorrhage (subarachnoid hemorrhage and cerebral hemorrhage); History of intracranial tumors, cerebral arteriovenous malformation, or aneurysm; Emergency endovascular intervention or intravenous thrombolysis before randomization; Dual antiplatelet therapy currently or within 14 days of randomization (excluding use of aspirin and clopidogrel after onset without loading dose of clopidogrel); Use of other antiplatelet drugs (ticagrelor, cilostazol, etc.), anticoagulant drugs, snake venom, defibrase, lumbrukinase or other defibrase treatments after onset; Expected long-term use of non-investigational antiplatelet drugs or non-steroidal anti-inflammatory drugs; With severe stenosis (> 70%) of parent artery giving off responsible penetrating artery; Definite indications for anticoagulation (suspicion of cardioembolism, e.g. atrial fibrillation, known heart valve prosthesis, atrial myxoma, endocarditis, etc.) or definite indications for dual antiplatelet therapy (e.g. recent coronary or cerebral artery stent implantation); Severe hepatic or renal insufficiency before randomization (severe hepatic insufficiency refers to ALT or AST > 3 times the upper limit of normal; severe renal insufficiency refers to creatinine clearance rate (CCr) < 30ml/min); Hemorrhagic tendency (including but not limited to):PLT<100×109/L; heparin treatment within 48h; APTT ≥ 35s; current use of warfarin, INR > 1.7; current use of novel oral anticoagulants; current use of direct thrombin or factor Xa inhibitor; Resistant hypertension which could not be controlled by medicine (SBP > 180mmHg or DBP > 110mmHg); History of obvious head trauma or stroke within three months of randomization; History of intracranial or intramedullary surgery within three months of randomization; History of major surgery or severe physical trauma within one month of randomization; Severe neurological defects (mRS ≥ 2) before the onset; Acute pericarditis; Hemorrhagic retinopathy; Childbearing-age women who do not take effective methods of contraception without negative records of pregnancy tests; Known to be allergic to tirofiban; Other surgical or interventional therapy planned within 3 months requiring experimental drugs discontinuation; Life expectancy < 6 months due to any terminal illness; Patients who are undergoing experimental drugs or instruments; Other conditions which suggest participants are unsuitable for this study, e.g. inability for understanding and / or obeying research procedures and / or follow-up due to mental diseases, cognitive or mood disturbance, or with MRI contraindications, etc.
Central Contact Person:
First Name & Middle Initial & Last Name or Official Title & Degree
Yilong Wang, PhD,MD
Phone
0086-010-67092222
Ext
0
Email
yilong528@aliyun.com
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Yilong Wang, PhD,MD
Organizational Affiliation
Beijing Tiantan Hospital, Capital Medical University, Beijing, China
Official's Role
Principal Investigator
Facility Information:
Facility Name
Beijing Hospital
City
Beijing
State/Province
Beijing
Country
China
Individual Site Status
Recruiting
Facility Name
The Affiliated Dongnan Hospital of Xiamen University
City
Zhangzhou
State/Province
Fujian
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Qingjin Li
Facility Name
Hejian People's Hospital
City
Hejian
State/Province
Hebei
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Dongqi Liu
Facility Name
The People's Hospital of Qinghe County
City
Xingtai
State/Province
Hebei
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Yingzhuo Zang
Facility Name
Mengzhou People's Hospital
City
Henan
State/Province
Henan
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Dali Li
Facility Name
The People's Hospital of Xiuwu County
City
Jiaozuo
State/Province
Henan
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Pingping Hou
Facility Name
Traditional Chinese Medicine Hospital of Jiyuan City
City
Jiyuan
State/Province
Henan
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Hongqin Yang
Facility Name
The First People's Hospital of Nanyang
City
Nanyang
State/Province
Henan
Country
China
Individual Site Status
Recruiting
Facility Name
The People's Hospital of Tanghe County
City
Nanyang
State/Province
Henan
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Hao Zhang
Facility Name
Traditional Chinese Medicine Hospital of Sui County
City
Shangqiu
State/Province
Henan
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Ying Li
Facility Name
The People's Hospital of Biyang County
City
Zhumadian
State/Province
Henan
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Shuo Zhang
Facility Name
Shaodong People's Hospital
City
Shaoyang
State/Province
Hunan
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Tingting Liu
Facility Name
The Third People's Hospital of Tongzhou District, Nantong City
City
Nantong
State/Province
Jiangsu
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Panbing Huang
Facility Name
The First People's Hospital of Xianyang
City
Xianyang
State/Province
Shaanxi
ZIP/Postal Code
712000
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Hao Zhu
Facility Name
Liaocheng Central Hospital
City
Liaocheng
State/Province
Shandong
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Hongyang Zhao
Facility Name
The People's Hospital of Guan County
City
Liaocheng
State/Province
Shandong
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Haijun Qiu
Facility Name
The Third People's Hospital of Liaocheng
City
Liaocheng
State/Province
Shandong
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Caijun Zhao
Facility Name
Weihai Wendeng District People's Hospital
City
Weihai
State/Province
Shandong
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Jinguo Zhao
Facility Name
Changzhi People's Hospital
City
Changzhi
State/Province
Shanxi
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Lihua Bao
Facility Name
The People's Hospital of Wanrong County
City
Yuncheng
State/Province
Shanxi
Country
China
Individual Site Status
Recruiting
Facility Contact:
First Name & Middle Initial & Last Name & Degree
Juan Wang

12. IPD Sharing Statement

Plan to Share IPD
No

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Study on Tirofiban With Aspirin in the Treatment of Acute Penetrating Artery Territory Infarction

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