FOcal Cerebral Arteriopathy Steroids (FOCAS) Trial

局灶性脑动脉病类固醇 (FOCAS) 试验

• 批准号: 10529923
• 负责人: MITCHELL S ELKIND
• 金额: $ 177.33万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-02-01 至 2024-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10529923
• 关键词: Acute; Address; Adrenal Cortex Hormones; Adverse effects; Advocacy; Affect; American; Arterial Disorder; Arteries; Aspirin; Attitude; Benefits and Risks; Blinded; Brain Injuries; Cerebral hemisphere hemorrhage; Characteristics; Chickenpox; Child; Childhood; Childhood stroke; Clinical; Clinical Trials; Communities; Consensus; Dangerousness; Data; Diagnosis; Diagnostic; Disadvantaged; Disease; Disease Progression; Distal; Dose; Early treatment; Enrollment; Etiology; European; Evolution; Family; Goals; Hemorrhage; Herpesviridae; Herpesviridae Infections; Hypertension; Image; Infarction; Infection; Inflammatory; Inflammatory Response; Internal carotid artery structure; International; Ischemic Brain Injury; Ischemic Stroke; Measures; Meta-Analysis; Minority; Motor; Natural History; Neurological outcome; Neurologist; Outcome; Outcome Measure; Patients; Pharmacotherapy; Physicians; Publication Bias; Publishing; Randomized; Randomized, Controlled Trials; Recommendation; Research; Research Personnel; Research Priority; Safety; Severities; Severity of illness; Site; Stenosis; Steroids; Stroke; Structure of trigeminal ganglion; Sum; Supportive care; Surveys; Testing; Time; Training; Transient Ischemic Attack; Uncertainty; Viral; Virus; arm; cerebral arteriopathy; cognitive disability; cohort; comparative effectiveness trial; compare effectiveness; improved outcome; post stroke; preference; prevent; primary endpoint; primary outcome; prospective; randomized placebo controlled trial; safety outcomes; secondary endpoint; secondary outcome; time interval; trial design

Focal cerebral arteriopathy of childhood (FCA)—one of the most common causes of arterial ischemic stroke in a healthy child—is an acute, monophasic, and presumed inflammatory arteriopathy of the distal internal carotid artery and its proximal branches. It has an aggressive natural history, typically progressing from mild arterial irregularity at presentation to high-grade stenosis within days. Greater severity of the arteriopathy correlates with larger infarct size and poorer neurological outcomes. The time interval from presentation to maximal severity represents a window of opportunity to intervene and improve outcomes. Current management includes aspirin, supportive care, and high-dose corticosteroids despite the absence of efficacy data. A Delphi consensus identified a clinical trial of corticosteroids for FCA as the highest research priority amongst international pediatric stroke neurologists. Surveys of U.S. pediatric stroke investigators also indicate an unwillingness to randomize children with FCA to “no steroids,” making a traditional randomized placebo- controlled trial infeasible. The most pressing clinical question is whether to treat all children with suspected FCA immediately or wait and treat only the subset that demonstrate the disease progression characteristic of FCA. Immediate treatment has the potential advantage of preventing FCA progression, but the disadvantage of diagnostic uncertainty at initial presentation, leading to unnecessary steroid exposure in children with other stroke etiologies. Clinicians also lack safety data needed for corticosteroid risk/benefit discussions with families of children with FCA. The primary aim of the Focal Cerebral Arteriopathy Steroid (FOCAS) trial is to compare the effectiveness of two strategies for treating suspected FCA with corticosteroids: (Strategy A) immediate treatment of all patients, versus (Strategy B) selective treatment of only those that demonstrate disease progression confirming the FCA diagnosis. The secondary aim is to determine the safety and tolerability of corticosteroid therapy in the setting of FCA and acute ischemic brain injury. Using a comparative-effectiveness trial design, FOCAS will prospectively enroll 80 children with suspected FCA presenting with arterial ischemic stroke or transient ischemic attack at 25 centers over 5.5 years and randomize them 1:1 to Strategy A or B. The primary endpoint will be an imaging outcome: change in FCA severity score from baseline to 1 month, measured by blinded central neuroradiologists comparing MRAs performed on the same scanner. Infarct volume at 1-month and neurological outcome at 6-months will be secondary endpoints. FOCAS safety outcomes will address clinical concerns for severe infection and hemorrhagic transformation of infarctions due to steroid-induced hypertension. The overall goal is to obtain clinically pertinent evidence that will immediately guide FCA management and help effect better outcomes for children with this dangerous arteriopathy.

儿童局灶性脑动脉病变（FCA）是健康儿童动脉缺血性中风最常见的病因之一，是一种急性、单相、推测为颈内动脉远端及其近端分支的炎症性动脉病变。它具有侵袭性的自然病史，通常从出现时的轻度动脉不规则发展到几天内的高度狭窄。动脉病变的严重程度越大，梗死面积越大，神经预后越差。从出现到最大严重程度的时间间隔代表了干预和改善结果的机会之窗。目前的治疗包括阿司匹林、支持治疗和大剂量皮质类固醇，尽管缺乏疗效数据。德尔菲共识确定皮质类固醇治疗FCA的临床试验是国际儿科卒中神经科医生的最高研究重点。对美国儿童卒中研究人员的调查也表明，不愿意将FCA患儿随机分配到“无类固醇”组，这使得传统的随机安慰剂对照试验不可行。最紧迫的临床问题是，是立即治疗所有疑似FCA的儿童，还是等待并仅治疗表现出FCA疾病进展特征的亚群。立即治疗具有防止FCA进展的潜在优势，但缺点是在初始表现时诊断不确定，导致其他中风病因的儿童不必要的类固醇暴露。临床医生也缺乏与FCA患儿家庭讨论皮质类固醇风险/益处所需的安全性数据。局灶性脑动脉病变类固醇（FOCAS）试验的主要目的是比较用皮质类固醇治疗疑似FCA的两种策略的有效性：（策略A）立即治疗所有患者，（策略B）仅对那些表现出疾病进展确认FCA诊断的患者进行选择性治疗。第二个目的是确定在FCA和急性缺血性脑损伤的情况下皮质类固醇治疗的安全性和耐受性。采用比较有效性试验设计，FOCAS将前瞻性地在25个中心招募80名在5.5年内出现动脉缺血性卒中或短暂性缺血性发作的疑似FCA儿童，并将他们1:1随机分配到策略a或b。主要终点将是成像结果：FCA严重程度评分从基线到1个月的变化，由盲法中枢神经放射学家比较在同一扫描仪上进行的mra进行测量。1个月时的梗死面积和6个月时的神经预后将是次要终点。FOCAS的安全性结果将解决由于类固醇诱导的高血压引起的严重感染和梗死出血转化的临床问题。总体目标是获得临床相关的证据，这些证据将立即指导FCA的管理，并帮助患有这种危险动脉病变的儿童获得更好的结果。