Study of the Combination Therapy of Rt-PA and Eptifibatide to Treat Acute Ischemic Stroke

The Combined Approach to Lysis Utilizing Eptifibatide and rt-PA in Acute Ischemic
Stroke-Enhanced Regimen (CLEAR-ER Stroke) trial is a Phase II trial and part of the
Specialized Program on Translational Research in Acute Stroke (SPOTRIAS). The overall goals
of SPOTRIAS are to enhance delivery of acute stroke patient care and train acute stroke
translational researchers.

Stroke most often occurs when blood flow to the brain stops because it is blocked by a blood
clot. When a blood clot blocks the blood supply to the brain, parts of the brain may not get
enough blood and oxygen to survive. As a result, permanent brain damage can occur, which can
affect a person's ability to walk, talk, and function independently. In order to reduce the
risk of permanent damage, it is important to restore blood flow to the brain as quickly as
possible.

rt-PA, used alone, is already approved by the Food and Drug Administration (FDA) as
treatment for patients with a stroke caused by blockage of an artery in the brain and when
given within 3 hours of the onset of stroke symptoms. Eptifibatide is also already
FDA-approved as a treatment for blood clots causing heart attack. The investigational aspect
of this study is the use of eptifibatide for a stroke victim in combination with rt-PA.

The CLEAR Stroke Trial demonstrated that the combination of low dose rt-PA plus eptifibatide
can be safely given to acute ischemic stroke patients within 3 hours of symptom onset.

The CLEAR-ER Stroke Trial is designed to provide data concerning the risks and benefits of
combining eptifibatide with medium dose intravenous rt-PA in 126 acute ischemic stroke
patients within 3 hours of symptom onset. Patients will be randomized to a combined
intravenous medium-dose rt-PA and eptifibatide regimen, or standard dose rt-PA in a 5 to 1
ratio. This will result in a total of 105 patients treated with a combined regimen, and 21
patients treated with standard dose IV rt-PA alone.

Inclusion Criteria:

- Patients must have a serious measurable neurological deficit on the NIH Stroke Scale
due to focal brain ischemia.

- An NIH Stroke Scale score >5 at the time the rt-PA is begun.

- Age: 18 through 85 years (i.e. candidates must have had their 18th birthday, but not
had their 86th birthday).

- Intravenous rt-PA therapy must be initiated within 3 hours of onset of stroke
symptoms.

Exclusion Criteria:

- History of stroke in the past 3 months.

- Previous intra-cranial hemorrhage, neoplasm, subarachnoid hemorrhage, or arterial
venous malformation.

- Clinical presentation suggests a subarachnoid hemorrhage, even if initial CT scan is
normal.

- Hypertension at time of treatment; systolic BP > 185 or diastolic > 110 mmHg or
aggressive measures to lower blood pressure to below these limits are needed.

- Presumed septic embolus.

- Presumed pericarditis including pericarditis after acute myocardial infarction.

- Recent (within 30 days) surgery or biopsy of parenchymal organ.

- Recent (within 30 days) trauma, with internal injuries or ulcerative wounds.

- Recent (within 90 days) severe head trauma or head trauma with loss of consciousness.

- Any active or recent (within 30 days) serious systemic hemorrhage.

- Known hereditary or acquired hemorrhagic diathesis, coagulation factor deficiency; or
oral anticoagulant therapy with INR > 1.7.

- Baseline lab values: positive urine pregnancy test, glucose < 50 or > 400 mg/dl,
platelets <100,000 /mm3, Hct <25 %, or creatinine > 4 mg/dl.

- Ongoing renal dialysis, regardless of creatinine.

- If heparin has been administered within 48 hours, the patient must have a normal
partial thromboplastin time (PTT).

- Arterial puncture at a non-compressible site or a lumbar puncture in the previous 7
days.

- Seizure at onset of stroke.

- Pre-existing neurological or psychiatric disease that would confound the neurological
or functional evaluations.

- Other serious, advanced, or terminal illness or any other condition that the
investigator feels would pose a significant hazard to the patient if rt-PA or
eptifibatide therapy were initiated.

- Patients whose peripheral venous access is so poor that they are unable to have two
standard peripheral intravenous lines started.

- Current participation in another research drug treatment protocol. Patient cannot
start another experimental agent until after 90 days.

- Informed consent is not or cannot be obtained.

- Any known history of amyloid angiopathy.

- High density lesion consistent with hemorrhage of any degree.

- Significant mass effect with midline shift.

- Large (more than 1/3 of the middle cerebral artery) regions of clear hypodensity on
the baseline CT scan. Sulcal effacement and/or loss of grey-white differentiation
alone are not contraindications for treatment.