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 Table of Contents  
STUDY PROTOCOL
Year : 2016  |  Volume : 1  |  Issue : 1  |  Page : 1-5

The optimal time window for the use and dosage of nimodipine for acute massive cerebral infarction: study protocol for a randomized controlled trial


Department of Neurology, Central Hospital Affiliated to Shenyang Medical College, Shenyang, Liaoning Province, China

Date of Web Publication31-Dec-2015

Correspondence Address:
Run-hui Li
Department of Neurology, Central Hospital Affiliated to Shenyang Medical College, Shenyang, Liaoning Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-7765.172998

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  Abstract 

Background: A neuroprotective effect of nimodipine on acute cerebral infarction has been confirmed, but there are few reports regarding the therapeutic effect of nimodipine on acute massive cerebral infarction. There is also no consensus on the optimal time window for the use and dosage of nimodipine. This trial is planned to answer these questions using a double-blind randomized controlled design.
Methods/Design: This is a double-blind randomized controlled trial. The experiments will be conducted in the Department of Neurology, Central Hospital Affiliated to Shenyang Medical College of China. One hundred patients with acute massive cerebral infarction will be randomly assigned to a control group and a treatment group. Patients in the control and treatment groups will receive intravenous infusion of citicoline and intravenous infusion of nimodipine (10 mg/d) respectively, for 7 consecutive days. Simultaneously, to determine the appropriate time window for treatment with nimodipine, patients in the treatment group will be divided into four subgroups according to the time of nimodipine administration: < 3 hours, 3-6 hours, 6-24 hours, and > 24 hours. The main outcome measures are: the National Institutes of Health Stroke Scale and the Rankin scale will be used to assess the severity and recovery of neurological impairment, respectively. Cranial computed tomography and magnetic resonance imaging will be used to evaluate brain lesions and the Barthel index will be used to assess the activities of daily living. Secondary outcome measures are heart rate and blood pressure.
Discussion: It is hoped that the experimental results can determine the best application time window and dosage of nimodipine for acute massive cerebral infarction.
Trial registration: ClinicalTrials.gov identifier: NCT02248233; registered on 22 September 2014.

Keywords: clinical trial; acute cerebral infarction; massive cerebral infarction; neurological function; nimodipine; activities of daily living; computed tomography; magnetic resonance imaging; randomized controlled trial


How to cite this article:
Li Rh. The optimal time window for the use and dosage of nimodipine for acute massive cerebral infarction: study protocol for a randomized controlled trial. Asia Pac J Clin Trials Nerv Syst Dis 2016;1:1-5

How to cite this URL:
Li Rh. The optimal time window for the use and dosage of nimodipine for acute massive cerebral infarction: study protocol for a randomized controlled trial. Asia Pac J Clin Trials Nerv Syst Dis [serial online] 2016 [cited 2018 Dec 19];1:1-5. Available from: http://www.actnjournal.com/text.asp?2016/1/1/1/172998


  Background Top


Large cerebral infarctions are also called massive cerebral infarctions and often indicate complete occlusion of the internal carotid artery, middle cerebral artery, or cortical branches. Massive cerebral infarction is a special type of cerebral infarction, and frequently occurs in people older than 60 years of age. Hypertension, diabetes, coronary heart disease, atrial fibrillation, and hyperlipidemia are major risk factors for massive cerebral infarction, which is of high concern because of the large affected area, resulting severe morbidity, and high mortality.

Acute cerebral infarction can cause calcium influx and intracellular calcium overload, promote free radical generation, and lead to brain injury (Horn et al., 2001). Calcium antagonists reduce calcium influx, inhibit free radical generation, and lessen brain injury (Wang and Ma, 2004). Nimodipine is a dihydropyridine calcium channel blocker that selectively affects cerebral vascular smooth muscle, expands cerebral blood vessels, increases cerebral blood flow, has protective effects on ischemic brain damage, and of special benefit, affects cerebral vasospasm-induced ischemic injury. Nimodipine specifically expands small intracranial arteries in the blood-brain barrier and has been recommended to treat cerebral small vessel disease (Gorelick et al., 2011). Nimodipine also has a small effect on peripheral blood vessels and the heart, unclearly affects cerebral steal syndrome, and contributes to the compensation and rehabilitation of neurological function. Nimodipine suppresses platelet aggregation, enhances erythrocyte deformability, decreases blood viscosity, and inhibits thrombosis. Nimodipine has also been shown to have neuroprotective effects on acute cerebral infarction (Long et al., 1998; Nag et al., 1998; Ahmed et al., 2000; Najarian and Traut, 2000; Ildan et al., 2001; Sobrado et al., 2003; Tomassoni et al., 2008). However, few studies have evaluated the therapeutic effect of nimodipine on acute massive cerebral infarction ([Table 1]), and none used a double-blind randomized controlled design. This study is designed to identify the optimal time window for nimodipine use and dosage.
Table 1: Previous studies addressing the treatment of acute massive cerebral infarction using nimodipine

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  Methods/Design Top


Study design

This is a double-blind randomized controlled trial. The experiments will be conducted in the Department of Neurology, Central Hospital Affiliated to Shenyang Medical College of China.

Study participants

One hundred patients with acute massive cerebral infarction, hospitalized in the Department of Neurology, Central Hospital Affiliated to Shenyang Medical College of China, will be recruited to participate in the study.

Inclusion criteria

  • First onset ≤ 80 years old and no severe complications related to internal diseases
  • Conscious or mild disturbance of consciousness with upper and lower limb paralysis on one side and muscle strength in the paralyzed limb grade 0-III
  • Computed tomographic (CT) scan that excludes cerebral hemorrhage and previous cerebral infarction (CT scan can reveal early massive infarction)
  • Blood pressure above or within the normal range


Exclusion criteria

  • Clinical manifestations significantly improved before treatment
  • Serious disturbance of consciousness such as drowsiness or coma
  • Mild neurological disorders, such as pure sensory disturbances, ataxia, dysarthria, and hemiparesis
  • Severe hypotension: systolic blood pressure < 90 mmHg, diastolic blood pressure < 60 mmHg
  • Heart rate < 60 beats/min or sinus bradycardia
  • Severe heart, brain, or kidney dysfunction, or malignant tumor


Randomization and interventions

Patient randomization will be performed using computerized randomization by a drug administrator. The treatment program for each subject will be generated using a random allocation sequence, and placed in ordered sealed opaque envelopes. When qualified subjects agree to participate, the envelopes will be opened and subjects will receive appropriate treatment measures. The blinded codes will be preserved by the drug administrator and subjects as participants are assigned to treatment and control groups. In accordance with the time of administration after onset, subjects in the treatment group will be divided into four subgroups (< 3 hours, 3-6 hours, 6-24 hours, and > 24 hours). Doctors, patients, and assessors will be blinded regarding patient group assignments to avoid measurement bias.

In the control group, subjects will receive 500 mL of physiological saline and 2.0 g/dose citicoline, intravenously, once per day, for 7 consecutive days. In the treatment group and with the same injection timing, subjects will receive 10 mg of nimodipine (Shandong Xinhua Pharmaceutical Co., Ltd., Zibo, China) in 500 mL of physiological saline in a covered container, intravenously. The initial intravenous rate will be 1-2 drops per minute and gradually increased if systolic blood pressure remains the same. The intravenous drip will be discontinued if systolic blood pressure drops by more than 10 mmHg. The maximum drip rate will be ≤ 10 drops per minute once per day for 7 days (Wang et al., 2014). During intravenous drug administration, a monitor will be used for blood pressure and heart rate continuous measurements. According to patient's conditions, subjects in both groups will be medicated to treat dehydration and upper gastrointestinal bleeding, preventing infection, and to maintain water and electrolyte balance. Symptomatic treatment will be conducted in patients with complications, such as coronary heart disease, hypertension, and diabetes. A packet flow chart of the trial is shown in [Figure 1].
Figure 1: Flow chart of the trial.

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Outcome measures

Primary outcomes: (1) the National Institutes of Health Stroke Scale (Brott et al., 1989) will be used to evaluate the severity of neurological impairment; (2) cranial CT scan and magnetic resonance imaging will be used to evaluate brain lesions; (3) the Rankin scale (Rankin, 1957) will be used to assess the recovery of neurological impairment; and (4) the Barthel index (Keith et al., 1987) will be used to evaluate the activities of daily living. Secondary outcomes: heart rate and blood pressure. Other outcomes: adverse reactions during medication, such as headache, dizziness, gastrointestinal symptoms, and changes in liver and kidney function. The timing of the outcome assessment is shown in [Table 2].
Table 2: Timing of outcome assessment

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Data management and statistical analysis

It is the responsibility of the researchers to ensure the accuracy of all data entered and recorded in the case-report forms (CRFs) and the database for his or her site. The data will be collected by the researchers onto a paper CRF for subsequent transcription to the electronic CRF.

A unique numeric identifier will be assigned to each patient, which will be entered as electronic data. The researchers will ensure that patient data are kept securely. Both physical and electronic storage of data will protect the security of these data and the confidentiality of participants. Follow-up will be completed by a professional researcher through medical record consultation and telephone contact. The primary and secondary outcome measures will be analyzed according to intention-to-treat principles.

All data will be analyzed using SAS 8.0 software (SAS Institute Inc., Carey, NC, USA). Numeration data will be expressed as percentages, and statistical differences will be compared using the chi-square test. Measurement data will be expressed as the the mean ± SD, and statistical differences between groups will be compared using the paired t-test or those among groups using analysis of variance and the least significant difference test. P < 0.05 will be considered statistically significant.

Ethical considerations and informed consent

This project has obtained the written approval of the Ethics Committee of Central Hospital Affiliated to Shenyang Medical College of China. Investigator or investigator-authorized personnel will explain the benefits and risks of participating in the study to each patient, patient's legitimate representative, or notary and witness, and obtain written informed consent. The study is in accordance with the guidelines of the Declaration of Helsinki, formulated by the World Medical Association.


  Discussion Top


Citicoline given to the control group is a membrane stabilizer, has neuroprotective effects, can promote cerebral metabolism and improve cerebral circulation by reducing cerebral vascular resistance and by increasing cerebral blood flow, contributes to the recovery of cerebral function, and has been extensively used to treat acute cerebral infarction (Alvarez-Sabνn and Romαn, 2013; Nomani and Kamal, 2013). Therefore, citicoline will be used as a positive control drug in our study.

Existing studies regarding nimodipine effects in acute massive cerebral infarction are mainly retrospective studies and non-randomized control studies, which cannot rule out the effects of non-drug therapies that may affect the objectivity of the results. These studies also have limitations such as small sample sizes and short-term follow-ups, which may have affected the results. Our proposed double-blind randomized controlled trial is designed to determine the optimal time window for the use and dosage of nimodipine to treat acute massive cerebral infarction and to provide effective evidence for the clinical application of nimodipine.

Trial status

Ongoing and recruiting at time of submission.

Conflicts of interest

None declared.

Author contributions

RHL conceived and designed the trial procedure, wrote the paper and approved the final version of the paper for publication.

Plagiarism check

This paper was screened twice using CrossCheck to verify originality before publication.

Peer review

This paper was double-blinded and stringently reivewed by international expert reviewers.[20]

 
  References Top

1.
Ahmed N, Näsman P, Wahlgren NG (2000) Effect of intravenous nimodipine on blood pressure and outcome after acute stroke. Stroke 31:1250-1255.  Back to cited text no. 1
    
2.
Alvarez-Sabín J, Román GC (2013) The role of citicoline in neuroprotection and neurorepair in ischemic stroke. Brain Sci 3:1395-1414.  Back to cited text no. 2
    
3.
Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V, et al. (1989) Measurements of acute cerebral infarction: a clinical examination scale. Stroke 20:864-870.  Back to cited text no. 3
    
4.
Gorelick PB, Scuteri A, Black SE, Decarli C, Greenberg SM, Iadecola C, Launer LJ, Laurent S, Lopez OL, Nyenhuis D, Petersen RC, Schneider JA, Tzourio C, Arnett DK, Bennett DA, Chui HC, Higashida RT, Lindquist R, Nilsson PM, Roman GC, et al. (2011) Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association. Stroke 42:2672-2713.  Back to cited text no. 4
    
5.
Horn J, de Haan RJ, Vermeulen M, Limburg M (2001) Very Early Nimodipine Use in Stroke (VENUS): a randomized, double-blind, placebo-controlled trial. Stroke 32:461-465.  Back to cited text no. 5
    
6.
Ildan F, Göçer AI, Tuna M, Polat S, Kaya M, Isbir T, Cetinalp E (2001) The effects of the pre-treatment of intravenous nimodipine on Na(+)-K+/Mg+2 ATPase, Ca+2/Mg+2 ATPase, lipid peroxidation and early ultrastructural findings following middle cerebral artery occlusion in the rat. Neurol Res 23:96-104.  Back to cited text no. 6
    
7.
Keith RA, Granger CV, Hamilton BB, Sherwin FS (1987) The functional independence measure: a new tool for rehabilitation. Adv Clin Rehabil 1:6-18.  Back to cited text no. 7
    
8.
Li YH (2002) A clinical study on nimodipine combined with Danshen in treatment of traumatic massive cerebral infarction. Zhejiang Zhongxiyi Jiehe Zazhi 12:545-546.  Back to cited text no. 8
    
9.
Liao SF, Chen HM, Wang YC, Huang GH, Guan DG, Wang WX, Yu JG (2013) Clinical study of nimodipine on large area cerebral infarction of severe traumatic brain injury after operation. Zhongguo Jiehe Linchuang 29:1070-1074.  Back to cited text no. 9
    
10.
Liu W, Gao ZQ, Li YT (2007) Therapeutic effects of cocktail therapy on massive cerebral infarction in 57 cases. Yaoxue yu Linchuang Yanjiu 15:401-402.  Back to cited text no. 10
    
11.
Long J, Wang G, Bai Y (1998) The effects of nimodipine on cerebrovascular function in acute cerebral infarction. Zhonghua Yi Xue Za Zhi 78:679-681.   Back to cited text no. 11
    
12.
Nag D, Garg RK, Varma M (1998) A randomized double-blind controlled study of nimodipine in acute cerebral ischemic stroke.Indian J Physiol Pharmacol 42:555-558.  Back to cited text no. 12
    
13.
Najarian T, Traut TW (2000) Nifedipine and nimodipine competitively inhibit uridine kinase and orotidine-phosphate decarboxylase: theoretical relevance to poor outcome in stroke. Neurorehabil Neural Repair 14:237-241.  Back to cited text no. 13
    
14.
Nomani F, Kamal AK (2013) Citicoline in the treatment of acute ischaemic stroke: an international, randomized, multicentre, placebo-controlled study (ICTUS trial) is the use of Citicoline is beneficial for acute ischaemic stroke? J Pak Med Assoc 63:1445.   Back to cited text no. 14
    
15.
Rankin J (1957) Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 2:200-215.  Back to cited text no. 15
    
16.
Sobrado M, López MG, Carceller F, García AG, Roda JM (2003) Combined nimodipine and citicoline reduce infarct size, attenuate apoptosis and increase bcl-2 expression after focal cerebral ischemia.Neuroscience 118:107-113.  Back to cited text no. 16
    
17.
Tomassoni D, Lanari A, Silvestrelli G, Traini E, Amenta F (2008) Nimodipine and its use in cerebrovascular disease: evidence from recent preclinical and controlled clinical studies. Clin Exp Hypertens 30:744-766.  Back to cited text no. 17
    
18.
Wang J, Li RH, Zhao LH (2014) Therapeutic effects of nimodipine on massive cerebral infarction. Zhongwai Jiankang Wenzhai 11:85-86.  Back to cited text no. 18
    
19.
Wang WZ, Ma QL (2004) The effect of nimodipine on bold free radicals and clinical outcome in patients with acute cerebral infart. Zhongguo Shenjing Mianyixue he Shenjingbing Xue Zazhi 11:210-212.  Back to cited text no. 19
    
20.
Yang SF (1998) A clinical study on nimodipine combined with heparin in treatment of massive cerebral infarction. Shiyan Yiji Zazhi 5:474-475.  Back to cited text no. 20
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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