Page 1
THE DAWN TRIAL AND THE STATUS OF ENDOVASCULAR TREATMENT FOR ACUTE STROKE
BEYOND 6 HOURS
Tudor G. Jovin, M.D.
Associate Professor of Neurology and NeurosurgeryDirector, UPMC Stroke Institute
Director UPMC Center for Neuroendovascular TherapyUniversity of Pittsburgh Medical Center
SHOULDTHEREBEATIMEWINDOWFORACUTESTROKEINTERVENTIONS???
Page 2
DISCLOSURES
Consultant/AdvisoryBoard:OwnershipInterest:SilkRoadMedical–modest
Consultant/AdvisoryBoard:Covidien/Medtronic:unpaid
Consultant:StrykerNeurovascularunpaid
PI:REVASCAT(FundacioIctusMalalGaVascular),unpaid
PI:DAWN(StrykerNeurovascular),unpaid
Consultant:CodmanNeurovascular(DSMBmember–modest)
Page 3
Infarct volume (both treatment groups) strongly correlates with clinical outcome
(p<0.0001) P<0.0001
SWIFTPRIME,AlbersG.,etal,Stroke2015 IMS3,JovinT.,etal,ISC2015
Page 4
DarbyDGetal.Stroke.1999;30(10):2043
0 6 12 18 24
%
Time(hr)A=erStrokeOnset
PenumbralCore
00
25
50
75
100
Ischemic Penumbra
CORE
Page 5
SERIALMRI’S(CORONALSECTIONS)ATTHREELEVELSINTHEBRAINDEPICTINGTHEAPPARENTDIFFUSIONCOEFFICIENTOFWATER(ADC)(MARKEDBYTHEBLUECOLOUR)DEMONSTRATINGTHETIME-DEPENDENTGROWTHOFTHEISCHEMICCORE.
PROGRESSIVE GROWTH OF CORE IN MCA OCCLUSION
Hossmanetal.,CellMolNeurobiol,2006
Page 6
DEFUSE2
-20
30
80
130
180
230
0 2 4 6 8 10 12
Baselin
eDW
IVolum
e(m
l)
TimebetweenSymptomOnsetandBaselineMRI(hrs)
Initial Growth Rate: Known Onset & M1 Occlusion
WheelerHM,etal.IntJStroke.2015
Page 7
DEFUSE2
-20
30
80
130
180
230
0 2 4 6 8 10 12
Baselin
eDW
IVolum
e(m
l)
TimebetweenSymptomOnsetandBaselineMRI(hrs)
Initial Growth Rate: Known Onset & M1 Occlusion
WheelerHM,etal.IntJStroke.2015
Page 9
Baseline MRI DEFUSE protocol
65YEAROLDMANPRESENTSWITHNIHSSOF15,9HOURSPOSTSX’SONSET.CTA-LICAOCCLUSION
Page 10
Khatri,LancetNeurology,2014
INTHEEARLYTIMEWINDOWIT’SALLABOUTTHETIMETOREPERFUSION
Every30minutedelayinreperfusionisassociatedwitha10%rela<vereduc<oninprobabilityof
goodclinicaloutcome(mRS0-2).
N=183MedianASPECTS:8
Page 11
Every30minutedelayinreperfusionisassociatedwitha5%rela<vereduc<oninprobabilityofgoodclinicaloutcome(mRS0-2).
Fransenetal.,JAMANeurol2016
RELATIONSHIPBETWEENTIMEFROMONSETTOREPERFUSIONANDGOODOUTCOMESINMRCLEAN
N=115MedianASPECTS=9
KHATRICURVEREVISITED
Page 12
RELATIONSHIPBETWEENONSETTOREPERFUSIONANDLIKELIHOODOFGOODOUTCOMEINESCAPE
CourtesyofDr.BMenon
N=113MedianASPECTS=9
Every30minutedelayinreperfusionisassociatedwitha0.5%rela<vereduc<oninprobabilityof
goodclinicaloutcome(mRS0-2).
KHATRICURVEREVISITED
Page 13
RELATIONSHIP BETWEEN TIME FROM ONSET TO REPERFUSION AND GOOD OUTCOMES IN REVASCAT
ProbabilityofmRS0-2-5%every30’ N=67
MedianASPECTS:7
RiboM,etal.,ESOC2015
Every30minutedelayinreperfusionisassociatedwitha5%rela<vereduc<oninprobabilityofgoodclinicaloutcome(mRS0-2).
KHATRICURVEREVISITED
Page 14
Only OR values with 95% CI < 1 are shown
-26% for each 30´ -28% for each 30´
-44% for each 30´ -50% for each 30´
LIKELIHOOD OF GOOD OUTCOME ACCORDING TO TIME INTERVALS FROM SX’S ONSET TO REPERFUSION AND
ASPECTS
Ribo et. al., Stroke, in press
Page 15
RELATIONSHIP BETWEEN TIME FROM ONSET TO REPERFUSION AND GOOD OUTCOMES IN DEFUSE 2
N=46Medianbaselineinfarctvolume=16cc
LansbergM.etal.,Neurology2015
Page 16
DEFUSE 2: Response to reperfusion is not time-dependent
in patients with salvageable tissue (mismatch)
16 LansbergandCereda,etal.Neurology;Aug2015
Treatment<6hoursTreatment>6hours
Page 19
WAKEUPSTROKEVSWITTNESEDONSETBEYOND8HRS-ISTHEREADIFFERFENCEINOUTCOMESWITHIAT?
AghaebrahimA.etal.,JNIS2015
Page 20
SHOULD WE TREAT PATIENTS WITH LVO AND MISMATCH BEYOND 6 HOURS WITH NO TIME LIMIT ???
Page 21
88 year old woman with L M1 occlusion, TLSW 22 hours, NIHSS 21, no intervenVon mRS at 3 weeks: 3
BaselineMRI/MRA–NIHSS21
4dayMRI/MRA–NIHSS11
MCAocclusion
MCAparGallyrecanalized
Page 22
88 year old woman with R M1 occlusion, TLSW 20 hours, NIHSS 17, no intervenVon mRS at 30 days 1
BaselineMRI/MRA
Follow-upMRI/MRAat24hours(NIHSS17)–noinfarctgrowthandparGalrecanalizaGon
Page 23
61 year old man with R M1 occlusion, TLSW 14 hours, NIHSS 21, no intervenVon 3 months mRS 4
BaselineMRI/MRA/CTP
MRI/MRAat24hours,NIHSS20
MRIatday5,NIHSS18
Page 24
OverviewTitle DWIorCTPAssessmentwithClinicalMismatchintheTriageof
WakeUpandLatePresenGngStrokesUndergoingNeurointervenGon(DAWN)
Sponsor StrykerNeyrovascularInc.
PIs TudorG.Jovin,MDandRaulG.Nogueira,MD
Funding StrykerNeurovascularInc.
Studydevice Trevo®ProVue™andTrevo®XPProVue™Retrievers
ControlintervenGon(IV-tPAyes/no?)
Bestmedicaltherapyincludingivt-PAineligiblepaGents(whichwillbeesGmatedtomakeupmaximium20%oftotal)
StudypopulaGon AcutestrokepaGentswithnoupperagelimitpresenGnginthe6-24hourGmewindowwithproximalanteriorcirculaGonocclusions(M1,ICAT)andsubstanGalclinical/coremismatch
ObjecGve ToevaluatethehypothesisthatTrevothrombectomyplusmedicalmanagementleadstosuperiorclinicaloutcomesat90daysascomparedtomedicalmanagementaloneinappropriatelyselectedsubjectsexperiencinganacuteischemicstrokewhentreatmentisiniGatedwithin6-24hoursamerlastseenwell.
Page 25
DAWN Trial: Why Do We Need to Do It?
Page 26
“PaGentseligibleforintravenousrtPAshouldreceiveintravenousrtPAevenifintra-arterialtreatmentsarebeingconsidered.”
ClassI LevelofEvidenceA UnchangedGuideline
EndovascularProtocolandPa`entSelec`on
PaGentsshouldreceiveendovasculartherapywithastentretrieveriftheymeetallthefollowingcriteria
a) prestrokemRSscore0to1,b) acuteischemicstrokereceivingintravenousr-tPAwithin4.5hoursofonset
accordingtoguidelinesfromprofessionalmedicalsocieGes,c) causaGveocclusionoftheinternalcaroGdarteryorproximalMCA(M1),d) age≥18years,e) NIHSSscoreof≥6,f) ASPECTSof≥6,andg) treatmentcanbeiniGated(groinpuncture)within6hoursofsymptomonset
NewRecommenda`onClassI LevelofEvidenceA
WilliamJ.Powers,ColinP.Derdeyn,JoséBiller,ChristopherS.Coffey,BrianL.Hoh,EdwardC.Jauch,KarenC.Johnston,S.ClaiborneJohnston,AlexanderA.Khalessi,ChelseaS.Kidwell,JamesF.Meschia,BruceOvbiagele,andDileepR.Yavagal.“2015AHA/ASAFocusedUpdateofthe2013GuidelinesfortheEarlyManagementofPaGentsWithAcuteIschemicStrokeRegardingEndovascularTreatment:AGuidelineforHealthcareProfessionalsFromtheAmericanHeartAssociaGon/AmericanStrokeAssociaGon.”AmericanHeartAssociaGonStrokeCouncil.StrokePublishedonlineJune29th2015.
Page 27
Raul Nogueira, MD
ForEvery10RandomizedPaGents
NNT=5
1:1RandomizaGon
5EndovascularArm 5ControlArm
DAWN
OpenRx
AssumingtheDAWNTreatmentParadigmisbeneficialandhasaverystrong
treatmenteffect(NNT=5)wewouldbemissingtheopportunitytohelponly1forevery10paGentsinthetrial
WhatistheWorstPriceWeCouldPay?
Page 28
Counterpoints Supporting Equipoise: Why DAWN Can Fail?
Longer Time from Stroke Onset to Treatment = ? Increased Risk of Hemorrhagic Transformation Longer Time from Stroke Onset to Treatment = ? Worse Reperfusion Rates Longer Time from Stroke Onset to Treatment = Better Collaterals = ? Better Natural History RCTs of Delayed IV Thrombolysis (including Mismatch-Based) Have Failed to Show a Benefit
Page 29
Copyright © 2014 Stryker NV00011894.AA | Released: December 2014 | Page 29 of 28
DAWN™ Trial
PrimaryObjecGveDWIorCTPAssessmentwithClinicalMismatchintheTriageofWake-UpandLatePresenGngStrokesUndergoingNeurointervenGon
ToevaluatethehypothesisthatTrevothrombectomyplusmedicalmanagementleadstosuperiorclinicaloutcomesat90daysascomparedwithmedicalmanagementaloneinappropriatelyselectedsubjectsexperiencinganacuteischemicstrokewhentreatmentisiniGatedwithin6-24hrsamerlastseenwell.
Page 30
Copyright © 2014 Stryker NV00011894.AA | Released: December 2014 | Page 30 of 28
Trevo® Retriever Thrombectomy Procedure
PhotographsandillustraGonsprovidedbyStrykerNeurovascular.
Page 31
Copyright © 2014 Stryker NV00011894.AA | Released: December 2014 | Page 31 of 28
• ProspecGve,randomized(1:1),mulG-center,PhaseII/III(feasibility/pivotal),adapGve,populaGonenrichment,blindedendpoint,controlledtrial
• Upto50sites(worldwide)• 150subjects(feasibility)upto500(pivotal)max• Primaryendpoint:
• DifferencebetweentheaverageweightedmRSat90daysbetweentreatmentandcontrolgroups
DAWN™ Trial Design
Page 32
Copyright © 2014 Stryker NV00011894.AA | Released: December 2014 | Page 32 of 28
DAWN™ Trial Unique Design Elements
PrimaryEndpoint:WeightedmRS
• DesignedtocapturehealthstatetransiGonsacrosstheenGrespectrum• EndpointthatisacombinaGonofbothefficacyandsafety• DifferenGatesoutcomes• PaGent-centeredoutcomesanalysis
Enrichment
• DesignedtofinetunethepaGentpopulaGonbasedoncoreinfarctsize• IdenGfysubgroupsexperiencingclinicalbenefit
mRS 0 1 2 3 4 5 6
Weight 10 9.1 7.6 6.5 3.3 0 0
Designedtomeasure
effecGveness&safetyinsingle
endpoint
0-50ccà0-45ccà0-40ccà0-35ccà0-30cc
hwp://dawntrial.trainingcampus.net
Page 33
Copyright © 2014 Stryker NV00011894.AA | Released: December 2014 | Page 33 of 28
UTILITY WEIGHTED MRS VS OTHER MODALITIES
Chasnainunkul,Saveretal.,Stroke2015
Page 34
Copyright © 2014 Stryker NV00011894.AA | Released: December 2014 | Page 34 of 28
DAWN™ Trial Unique Design Elements
ClinicalImagingMismatch
• Standardizesclinicalimagingtoselectsubjects
• LiteraturesupportscoreinfarctsizebeingpredicGveofoutcomes
• NIHSSassessment(clinicaldeficit)representsGssueatriskinrealGme,canbeeasilyadministered(andrepeated)mulGpleGmes,andisvalidatedinclinicalpracGce
Page 35
CLINICAL EXAM (NIHSS): A GOOD ESTIMATION OF THE AT RISK TERRITORY ??
Davalosetal.,Neurology2004
Page 36
DAWN™ Clinical Trial
RandomizaGonBalancedre:CIMsubgroup,GmeandocclusionlocaGon
StandardizedRAPIDsomware
ProximalOcclusion:
ICA-Tand/orMCA-M1Occlusion
ClinicalMismatch:
NIHSS>10
+SmallInfarct
Goal: To idenVfy the Target Mismatch PaVent in the 6-24h Window (including Wake-Up Strokes)
Page 37
Copyright © 2014 Stryker NV00011894.AA | Released: December 2014 | Page 37 of 28
ClinicalImagingMismatch(CIM)definedasoneofthefollowingonRAPIDMR-DWIorCTP-rCBFmaps:
a. 0-20cccoreinfarct&NIHSS≥10(&≥80yrsold)b. 0-30cccoreinfarct&NIHSS≥10(&<80yrsold)c. 31to≤50cccoreinfarct&NIHSS≥20(&<80yrsold)
WriwenConsentfromsubjectorLAR(ifnotobtainedpriortoRAPID)
Age≥18NIHSS≥10
Pre-strokemRS0-1<1/3MCAterritoryinvolved,asevidencedbyCTorMRI
OcclusionoftheintracranialICAand/orMCA-M1,byMRAorCTASubjectcanberandomizedwithin6-24hfromTLSW
DAWN Flow Chart – Screening and Enrollment
Page 38
Copyright © 2014 Stryker NV00011894.AA | Released: December 2014 | Page 38 of 28
RAPIDSo=warestandardizesmeasurementofcoreinfarctsize• SupportsobjecGvityinarandomizedclinicaltrial• Especiallyimportantfor6+hourpaGentpopulaGonwithunknowntreatmenteffect
• ONLYtheRAPIDcoreinfarctsizemaybeusedtodetermineeligibilityandstraGficaGon
• MRI-DWIorCTP-rCBF• 510(k)clearedhoweverDAWNTrialversioncanONLYbeusedforstudysubjectevaluaGon
• BaselineNIHSSmustbeobtainedwithin1houroftheRAPIDprocessedimagesusedforqualificaGon
DAWN™ Trial uses RAPID Socware
Page 39
Copyright © 2014 Stryker NV00011894.AA | Released: December 2014 | Page 39 of 28
Safety Outcomes
• Incidenceofstroke-relatedmortalityat90days• IncidenceofsICH,byECASSIIIdefiniGon,within24(-6/+24)hrspostrandomizaGon(Gmezero)
• IncidenceofneurologicaldeterioraGonfrombaselineNIHSSscorethroughDay5-7/Discharge(whicheverisearlier)postrandomizaGon(Gmezero).NeurologicaldeterioraGonisdefinedas≥4pointincreaseintheNIHSSscorefromthebaselinescore.
Page 40
Copyright © 2016 Stryker Confidential NV00018223.AA | Page 40 of 64
Site Status Maximum Number of Sites 31 Contracts Executed 21 Sites Qualified 31 Initiation Training Complete 26 IRB/EC Approvals 28 Subjects Enrolled 74
DAWN Trial Update (as of 18-Feb-2016)
Actual / Projected Enrollment
Page 41
Copyright © 2016 Stryker Confidential NV00018223.AA | Page 41 of 64
Enrollment by Authorized Site (as of 18-Feb-2016)
0
0
0
0
0
0
0
1
1
1
2
2
2
4
5
6
7
17
26
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30
Baptist Jacksonville (Dr. Hanel, ATE 01/21/16)
Christiana (Dr. Satti, ATE 01/21/16)
Kaiser LA (Dr. Feng, ATE 11/19/15)
Royal Melbourne (Dr. Mitchell, ATE 11/12/15)
KUMC (Dr. Abraham, ATE 02/01/16)
Florida Hospital (Dr. Hellinger, ATE 11/09/15)
Rush (Dr. Chen, ATE 05/07/15)
Buffalo (Dr. Levy, ATE 12/01/15)
CPMC (Dr. English, ATE 05/05/15)
Capital (Dr. Vez, ATE 07/01/14)
Erlanger (Dr. Devlin, ATE 06/05/15)
Hopital Purpan Toulouse (Dr. Cognard, ATE 01/28/16)
Abington (Dr. Shah, ATE 10/29/15)
Valley Baptist (Dr. Hassan, ATE 03/31/15)
UH Cleveland (Dr. Sila, ATE 05/04/15)
Riverside (Dr. Budzik, ATE 08/28/14)
Texas Stroke Institute (Dr. Bhuva, ATE 04/10/15)
Grady (Dr. Nogueira, ATE 11/25/14)
UPMC (Dr. Jadhav, ATE 10/31/14)
Page 42
Copyright © 2016 Stryker Confidential NV00018223.AA | Page 42 of 64
DAWN Time Points
61
111
133
78
27
0
20
40
60
80
100
120
140
Door to
Imaging
Door to
Randomization
Door to
Puncture
Imaging to
Puncture
Randomization to
Puncture
DAWN Trial Median Time Points (Minutes)
Page 43
Copyright © 2014 Stryker NV00011894.AA | Released: December 2014 | Page 43 of 28
CURRENT ENROLLMENT STATUS
Page 44
• Stroke/Interven`onalNeurology• TudorJovin,MD
• AshuJadhav,MDPhD
• LawrenceWechsler,MD
• MaximHammer,MD
• VivekReddy,MD
• MawStarr,MD
• ViktoriaTotoraiGs,MD
• NimaAghaebrahim,mD
• DanVictorGiurgiuGu,MD
• VascularEndovascularNeurosurgery• BrianJankowitz,MD
• AndrewDucruet,MD
• RobertFriedlander,MD
• PaulGardner,MD
• DanWecht,MD
• StrokeIns`tuteNursingStaff• LoriMassaro–CRNP
• SusanKim-CRNP
• MariaAbraham–PA
• ChrisGnaBonaccorsi–PA
• KathySeiler,RN
• CherieAdamsRN
• JonyaBrooks,RN
• KenCoval,RN
• Pa{Williams,RN
• Neurocri`calCare• BradMolyneaux,MD
• LoriShuwer,MD
• SherryChou,MD
• RuchiJha,MD
• KeesPolderman,MD
• Neuroanesthesia• ColeenMoran,MD
• FrankGyulai,MD
• TheresaGelzinis,MD
• EmergencyMedicine• CharissaPacella,MD
• FrankGuyewe,MD
• ChrisGill-MarGn,MD
• CliffCallaway,MD
• DonYealy,MD
• MikeTurturro,MD
• MariaGuyewe,MD
• Neuroradiology• BillDelfyew,MD
• CharBranstewer,MD
• EmanuelKanal,MD
• StrokeIns`tuteResearchStaff• LisaBaxendell–Researchcoord
• CarlynnGraves–Researchcoord
• PatriciaPorter–Researchcoord
• KaraArmbruster–Researchcoord
• YvonneCannon–Researchcoord
• HollyKromer-DataManagement
• NeuroIRRadiologyTechs&NursingStaff• KiwyO’Toole,RTVI
• CaseyFoster,RTVI
• JenniferHamil,RTVI
• JimBozak,RTVI
• JasonPaul,RTVI
• CandaceAcklin,RN
• JosieStashko,RN
• Neurorahabil`a`on• JenniferShen
• CaraCamiolo
• MikeBonimnger
• NeuroscienceNursing• MelanieSmith,RN
• BenMorrow,RN
• KateSpiering,RN
• ThereseDawson,RN
UPMCACUTEENDOVASCULARSTORKETEAM