Severe Traumatic Brain Injury Clinical Trial
Official title:
Phase 2, Randomized Clinical Trial of the Safety and Efficacy of Brain Tissue Oxygen Monitoring in the Management of Severe Traumatic Brain Injury.
Traumatic brain injury (TBI) is a major cause of death and disability, with an estimated cost
of 45 billion dollars a year in the United States alone. Every year, approximately 1.4
million sustain a TBI, of which 50,000 people die, and another 235,000 are hospitalized and
survive the injury. As a result, 80,000-90,000 people experience permanent disability
associated with TBI. This project is designed to determine whether a device designed to
measure brain tissue oxygenation and thus detect brain ischemia while it is still potentially
treatable shows promise in reducing the duration of brain ischemia, and to obtain information
required to conduct a definitive clinical trial of efficacy.
A recently approved device makes it feasible to directly and continuously monitor the partial
pressure of oxygen in brain tissue (pBrO2). Several observational studies indicate that
episodes of low pBrO2 are common and are associated with a poor outcome, and that medical
interventions are effective in improving pBrO2 in clinical practice. However, as there have
been no randomized controlled trials carried out to determine whether pBrO2 monitoring
results in improved outcome after severe TBI, use of this technology has not so far been
widely adopted in neurosurgical intensive care units (ICUs). This study is the first
randomized, controlled clinical trial of pBrO2 monitoring, and is designed to obtain data
required for a definitive phase III study, such as efficacy of physiologic maneuvers aimed at
treating pBrO2, and feasibility of standardizing a complex intensive care unit management
protocol across multiple clinical sites.
Patients with severe TBI will be monitored with Intracranial pressure monitoring (ICP) and
pBrO2 monitoring, and will be randomized to therapy based on ICP along (control group) or
therapy based on ICP in addition to pBrO2 values (treatment group). 182 participants will be
enrolled at four clinical sites, the University of Texas Southwestern Medical Center/Parkland
Memorial Hospital, the University of Washington/Harborview Medical Center, the University of
Miami/Jackson Memorial Hospital, and the University of Pennsylvania/Hospital of the
University of Pennsylvania. Functional outcome will be assessed at 6-months after injury.
Design and Outcomes
This study is a two-arm, single-blind, randomized, controlled, phase II, multi-center pilot
trial of the efficacy of pBrO2 monitoring, and is designed to obtain data required for a
definitive phase III study, such as efficacy of physiologic maneuvers aimed at normalizing
pBrO2. 182 patients with severe TBI who require ICP monitoring will be recruited into this
study at 4 clinical sites in the US (Univ. of Texas Southwestern/Parkland Memorial Hospital,
Univ. of Washington/Harborview Medical Center, Univ. of Miami/Jackson Memorial Hospital, and
Univ. of Pennsylvania/Hospital of the Univ. of Pennsylvania). All patients will have both ICP
monitors and pBrO2 monitors inserted through the same burr hole. Half of the patients will be
randomized to a treatment protocol based on both ICP and pBrO2 readings, while the control
group will be randomized to a treatment protocol based only on ICP readings. The
pBrO2monitors of the control arm will be masked, so that the treating physicians will be
unaware of the pBrO2 information. Patients will have telephone follow-up interview to assess
their level of recovery 6 months post injury, using the Glasgow Outcome Scale-Extended.
Interventions and Duration
Patients randomized to the control group will have pBrO2 implanted in a similar fashion as
patients in the treatment group, but after calibration of the device, the display will be
covered with opaque tape. Patients in the control will be treated with a protocol based on
ICP measures only. Patients in the treatment group (both ICP and pBrO2 measures are visible)
will be treated according to a protocol that incorporates both ICP and pBrO2 measures. The
treatment protocols are based on current standards of care, but are described in detail to
insure uniformity in treatments across the 4 study sites.
The probe will remain in place for a maximum or 5 days, until all values are normal for 48
hours, or sooner if a complication arises. If the patient has normal values, monitors will be
removed after 48 hours.
Objectives
Primary Objective: The prescribed treatment protocol, based on pBrO2 monitoring, results in
reduction of the fraction of time that brain oxygen levels are below the critical threshold
of 20 mm Hg in patients with severe traumatic brain injury.
Secondary Objectives:
- Safety hypotheses: Adverse events associated with pBrO2 monitoring are rare.
- Feasibility hypotheses: Episodes of decreased pBrO2 can be identified and treatment
protocol instituted comparably across 4 clinical sites, and protocol violations will be
low (<10%) and uniform across different clinical sites.
- Non-futility hypothesis: A relative risk of good outcome measured by the Glasgow Outcome
Scale-Extended 6 months after injury of 2.0 is consistent with the results of this phase
II study.
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