- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT05860855
The AGAINST Protocol: Augmentative Craniotomy in Stroke (AGAINST)
The AGAINST Protocol: Augmentative Craniotomy in Stroke: a Prospective, Randomized, Controlled, Multicentre, Comparative Trial on Decompressive Craniectomy and Augmentative Craniotomy in Malignant Middle Cerebral Infarction
Study Overview
Status
Intervention / Treatment
Detailed Description
AGAINST is a prospective, randomised, controlled, open, multicentre, two-armed, comparative trial. Patients are randomised 1:1 to either treatment with hemicraniectomy or with augmentative craniotomy. Complete blinding is virtually impossible both for treating physicians and patients due to visible aesthetic differences between the two groups. All participating centers dispose of 24/h per day neurosurgical facilities. Ethical boards of each participating center approved the present trial protocol. The enrollment will stop as soon as statistical difference between two groups would be reached. The study design of the present clinical trial protocol adhere to the SPIRIT and CONSORT guidelines.
Treatment protocol
Patients who pass the screening of inclusion and criteria will be considered suitable for the enrollment in the study. After medical evaluation and neuroimaging, written informed consent will be obtain before enrolling the patient in the study. Then, randomization is performed online (trough http//:randomizer.at) and, if the online randomization fails, patients will be randomized through a sealed envelope system managed by a 24-h/7-day phone service. Consequentially, the patient is assigned to one of the following groups of treatment: Group I, augmentative craniotomy; Group 2, decompressive hemicraniectomy. Surgical treatment will be performed not later than 48 hours after symptoms onset and not later than 6 hours after randomization.
The allocation ratio between the two groups is 1:1.
Augmentative craniotomy
Surgical incision according to "Kempe" is performed to obtain a better vascularization of the myo-cutaneous flap, to guarantee a larger surgical exposition and to facilitate the closure. The incision starts from "widow's peak" and arrives 1 cm upon the inion and it is performed parallel to the midline, 3 cm from it. If exposition of the keyhole is requested, frontal incision line can be extended 2 cm along the ipsilateral hairline. Then a second incision is performed from the center of the first one and it will be extended inferiorly to the tragus. Burr holes will be performed in the frontal-basal region (keyhole), temporal region and superior and medial to the inion. Supplementary burr holes can be performed the superior margin of the skin incision. Then, a large frontal-temporal-parietal-occipital craniotomy not smaller than 12x15 cm (area >140 cm2) is performed, according to Brain Trauma Foundation guidelines12. Then the dura is opened in a "star" shape and dural augmentation is performed with the positioning of a dural patch. The operculum is repositioned through the application of 5 titanium clamps secured with screws 1 cm above the margin of the craniotomy. The myo-cutaneous flaps are reapproximated and sealed.
Decompressive craniectomy
The procedure of hemicraniectomy is performed in the same way as the augmentative craniotomy from skin incision to dural augmentation. Then, the myo-cutaneous flaps are reapproximated and sealed and the operculum is secured. Then, cranioplasty with autologous bone will be performed within 6-months after the hemicraniectomy.
Data collection, statistical analysis and duration
For patients in both groups at baseline a complete clinical and neurological evaluation will be performed an all the following data will be collected: age, sex, weight, NIHSS, modified Rankin Score (MRS), time and date onset of symptoms, Glasgow Coma Scale (GCS), Barthel Index, neuroimaging data (CT and MRI scans showing timing of the ischemic stroke, ischemic core infarction volume), comorbidities. At 6- and 12-months a complete medical and neurological evaluation will be performed along with MRI scans. Data related to primary and secondary endpoints will be registered: NIHSS, MRS, Barthel Index, SF-36, EuroQoL 5D, presence of sunken flap syndrome, presence of hydrocephalus.
Study Type
Enrollment (Anticipated)
Phase
- Not Applicable
Contacts and Locations
Study Contact
- Name: Luigi Valentino Berra, M.D.
- Phone Number: +393491475626
- Email: l.berra@policlinicoumberto1.it
Study Contact Backup
- Name: Mauro Palmieri, M.D.
- Phone Number: +393461316999
- Email: mauro.palmieri@uniroma1.it
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
- Adult
- Older Adult
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Only MCA ischemic strokes have been considered, with no distinctions between the execution of precedent treatment (thrombolysis and/or thrombectomy)
- Patients' age <75 years old.
- NIHSS >1a, >14 for right sided lesions, >15 for left sided lesions
- Symptoms onset <48 hours before surgery or conservative treatment
- Neuroradiological findings: unilateral ischemic infarction of at least 1/3 of MCA territory is involved. Ischemic core volume>140ml. Hypodensity on head CT within the first 6 hours of stroke onset involving one-third or more of the MCA territory, early midline shift, and magnetic resonance imaging diffusion-weighted imaging volume within 6 hours ≥80 mL.
- informed consent by the patient him/herself, his/her legal representative, adjudication by a legally competent judge, or by an independent physician
Exclusion Criteria:
- - presence of concomitant or associated brain lesion
- presence of concomitant comorbidities or other clear contraindications for treatment
- participation in any other interventional trial
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Single
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Active Comparator: Decompressive hemicraniectomy
The procedure of hemicraniectomy is performed in the same way as the augmentative craniotomy from skin incision to dural augmentation.
Then, the myo-cutaneous flaps are reapproximated and sealed and the operculum is secured.
Then, cranioplasty with autologous bone will be performed within 6-months after the hemicraniectomy.
|
Standard hemicraniectomy
|
Experimental: Augmentative craniotomy
Surgical incision according to Kempe is performed to obtain a better vascularization of the myo-cutaneous flap, to guarantee a larger surgical exposition and to facilitate the closure.
The incision starts from "widow's peak" and arrives 1 cm upon the inion and it is performed parallel to the midline, 3 cm from it.
Then a second incision is performed from the center of the first one and it will be extended inferiorly to the tragus.
Burr holes will be performed in the frontal-basal region (keyhole), temporal region and superior and medial to the inion.
Supplementary burr holes can be performed.
Then, a large frontal-temporal-parietal-occipital craniotomy not smaller than 12x15 cm is performed.
Then dural augmentation is performed with the positioning of a dural patch.
The operculum is repositioned through the application of 5 titanium clamps secured with screws 1 cm above the margin of the craniotomy.
The myo-cutaneous flaps are reapproximated and sealed.
|
Expansion of the skull
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Changes in functional and neurological status
Time Frame: From recruitment to 12 months
|
Modified Rankin score(mRS) ranges from 0 to 6. Lower points represent better outcomes
|
From recruitment to 12 months
|
Changes in quality of life
Time Frame: From recruitment to 12 months
|
36-item short form survey (SF-36) ranges from 0 to 100.
Lower points represent worse outcomes
|
From recruitment to 12 months
|
Changes in functional and neurological status
Time Frame: From recruitment to 12 months
|
Barthel index ranges from 0 to 100.
Lower points represent worse outcomes
|
From recruitment to 12 months
|
Changes in functional and neurological status
Time Frame: From recruitment to 12 months
|
National Institute of Health Stroke Scale (NIHSS), ranges from 0 to 42.
Lower point represent better outcomes
|
From recruitment to 12 months
|
Changes in quality of life
Time Frame: From recruitment to 12 months
|
EuroQol 5D (EQ-5D) ranges from 0 to 100.
Lower point represent worse outcomes
|
From recruitment to 12 months
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
surgical complications
Time Frame: From recruitment to 12 months
|
haemorrhage requiring blood transfusions, anaesthesia-related incidents, pharmacological treatment, impaired wound healing or wound infection, liquor fistula, hygroma, or any other secondary complication leading to prolongation of hospitalization or rehospitalization.
The incidence of hydrocephalus and sunken flap syndrome
|
From recruitment to 12 months
|
Collaborators and Investigators
Sponsor
Investigators
- Principal Investigator: Luigi Valentino Berra, University of Roma La Sapienza
Study record dates
Study Major Dates
Study Start (Anticipated)
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Ischemia
- Pathologic Processes
- Necrosis
- Cardiovascular Diseases
- Vascular Diseases
- Cerebrovascular Disorders
- Brain Diseases
- Central Nervous System Diseases
- Nervous System Diseases
- Brain Ischemia
- Stroke
- Brain Infarction
- Cerebral Arterial Diseases
- Intracranial Arterial Diseases
- Infarction
- Cerebral Infarction
- Infarction, Middle Cerebral Artery
Other Study ID Numbers
- AGAINST 001
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
IPD Sharing Supporting Information Type
- STUDY_PROTOCOL
- SAP
- ICF
- CSR
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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