PROTOCOL

PROTOCOL APPROVAL

CONFIDENTIAL STATEMENT

TABLE OF CONTENTS

1. BACKGROUND ..... 15
   1.1 Background on Acute Ischemic Stroke ..... 15
   1.2 Background on Alteplase ..... 15
   1.2.1 Fibrinolysis and Tissue Plasminogen Activator ..... 15
   1.3 Study Rationale and Benefit-Risk Assessment ..... 16
2. OBJECTIVES ..... 18
   2.1 Primary Objectives ..... 18
   2.2 Secondary Objectives ..... 18
   2.3 Exploratory Objectives ..... 19
3. STUDY DESIGN ..... 19
   3.1 Description of Study ..... 19
   3.2 Length of Study ..... 20
   3.3 End of Study ..... 20
   3.3.1 Number of Patients ..... 20
   3.4 Rationale for Study Design ..... 21
   3.4.1 Rationale for Alteplase Dosage ..... 21
   3.4.2 Rationale for Patient Population ..... 21
   3.4.3 Rationale for Control Group ..... 23
   3.5 Outcome Measures ..... 24
   3.5.1 Efficacy Outcome Measures ..... 24
   3.5.2 Safety Outcome Measures ..... 24
   3.5.3 Exploratory Outcome Measures ..... 25
4. MATERIALS AND METHODS ..... 25
   4.1 Patients ..... 25
   4.1.1 Inclusion Criteria ..... 25
   4.1.2 Exclusion Criteria ..... 26
   4.2 Method of Treatment Assignment and Blinding ..... 27
   4.3 Study Treatment ..... 29
   4.3.1 Formulation, Packaging, and Handling ..... 29
   4.3.1.1 Alteplase ..... 29
   4.3.1.2 Alteplase Placebo ..... 29
   4.3.1.3 Aspirin ..... 29
   4.3.1.4 Aspirin Placebo ..... 30
   4.3.2 Dosage, Administration, and Compliance ..... 30
   4.3.2.1 Alteplase ..... 30
   4.3.3 Investigational Medicinal Product Accountability ..... 31
   4.3.4 Investigational Medicinal Product ..... 31
   4.3.4.1 Alteplase and Placebo ..... 31
   4.3.4.2 Non-investigational Medicinal Products ..... 31
   4.3.5 Post-Trial Access to Alteplase ..... 31
   4.4 Concomitant Therapy ..... 32
   4.4.1 Permitted Therapy ..... 32
   4.4.2 Prohibited Therapy ..... 32
   4.5 Study Assessments ..... 32
   4.5.1 Description of Study Assessments ..... 32
   4.5.1.1 Informed Consent Forms and Screening Log ..... 32
   4.5.1.2 Medical History and Demographic Data ..... 33
   4.5.1.3 Neurological Examinations ..... 33
   4.5.1.4 Vital Signs ..... 33
   4.5.1.5 Laboratory Assessments ..... 33
   4.5.1.6 Other Disease-Specific Assessments ..... 34
   4.5.2 Patient-Reported Outcomes ..... 34
   4.6 Timing of Study Assessments ..... 35
   4.6.1 Screening/Baseline (Visit 1) ..... 35
   4.6.2 Visit 2 (22 to 36 Hours after Treatment Initiation) ..... 36
   4.6.3 Visit 3 (Day 5 or Discharge from Hospital, if Sooner than Day 5) ..... 36
   4.6.4 Visit 4 (Day 30 [ Days]) ..... 36
   4.6.5 Visit 5 (Day Days]/Study Completion) ..... 36
   4.6.6 Early Discontinuation ..... 37
   4.7 Patient, Treatment, Study, and Site Discontinuation ..... 37
   4.7.1 Patient Discontinuation ..... 37
   4.7.2 Study Treatment Discontinuation ..... 37
   4.7.3 Study and Site Discontinuation ..... 38
5. ASSESSMENT OF SAFETY ..... 38
   5.1 Safety Plan ..... 38
   5.1.1 Risk of Bleeding ..... 38
   5.1.2 Risk of Allergic Reactions ..... 39
   5.2 Safety Parameters and Definitions ..... 39
   5.2.1 Adverse Events ..... 40
   5.2.2 Serious Adverse Events (Immediately Reportable to the Sponsor) ..... 40
   5.2.3 Non-Serious Adverse Events of Special Interest (Immediately Reportable to the Sponsor) ..... 41
   5.3 Methods and Timing for Capturing and Assessing Safety Parameters ..... 41
   5.3.1 Adverse Event Reporting Period ..... 41
   5.3.2 Assessment of Severity of Adverse Events ..... 42
   5.3.3 Assessment of Causality of Adverse Events ..... 42
   5.3.3.1 Diagnosis versus Signs and Symptoms. ..... 43
   5.3.3.2 Adverse Events Occurring Secondary to Other Events ..... 43
   5.3.3.3 Persistent or Recurrent Adverse Events ..... 44
   5.3.3.4 Abnormal Laboratory Values ..... 44
   5.3.3.5 Abnormal Vital Sign Values ..... 45
   5.3.3.6 Deaths ..... 45
   5.3.3.7 Preexisting Medical Conditions ..... 46
   5.3.3.8 Lack of Efficacy or Worsening of Acute Ischemic Stroke ..... 46
   5.3.3.9 Hospitalization or Prolonged Hospitalization ..... 46
   5.3.3.10 Adverse Events Associated with an Overdose ..... 46
   5.3.3.11 Patient-Reported Outcome Data ..... 47
   5.4 Immediate Reporting Requirements from Investigator to Sponsor ..... 47
   Alteplase-Genentech, Inc.
   5.4.1 Emergency Medical Contacts ..... 47
   5.4.2 Reporting Requirements for Serious Adverse Events and Non-Serious Adverse Events of Special Interest ..... 48
   5.4.3 Reporting Requirements for Pregnancies ..... 48
   5.4.3.1 Pregnancies in Female Patients ..... 48
   5.4.3.2 Congenital Anomalies/Birth Defects and Abortions ..... 48
   5.5 Follow-Up of Patients after Adverse Events ..... 49
   5.5.1 Investigator Follow-Up ..... 49
   5.5.2 Sponsor Follow-Up ..... 49
   5.6 Post-Study Adverse Events ..... 49
   5.7 Expedited Reporting to Health Authorities, Investigators, Institutional Review Boards, and Ethics Committees ..... 50
6. STATISTICAL METHODS ..... 50
   6.1 Determination of Sample Size ..... 50
   6.2 Primary Analysis ..... 50
   6.3 Safety Analysis ..... 51
   6.4 Exploratory Analyses ..... 51
   6.5 Interim Analysis ..... 52
   6.6 Missing Data Handling ..... 52
7. DATA COLLECTION AND MANAGEMENT ..... 52
   7.1 Data Quality Assurance ..... 52
   7.2 Electronic Case Report Forms ..... 53
   7.3 Source Data Documentation ..... 53
   7.4 Use of Computerized Systems ..... 54
   7.5 Retention of Records ..... 54
8. ETHICAL CONSIDERATIONS ..... 54
   8.1 Compliance with Laws and Regulations ..... 54
   8.2 Informed Consent ..... 55
   8.3 Institutional Review Board or Ethics Committee ..... 55
   8.4 Confidentiality ..... 56
   8.5 Financial Disclosure ..... 56
   Alteplase-Genentech, Inc.
   Protocol ML29093, Version 1 ..... 5
9. STUDY DOCUMENTATION, MONITORING, AND ADMINISTRATION ..... 56
   9.1 Study Documentation ..... 56
   9.2 Protocol Violations ..... 57
   9.3 Site Inspections ..... 57
   9.4 Administrative Structure ..... 57
   9.5 Protocol Amendments ..... 58
10. REFERENCES ..... 59
    LIST OF TABLES
    Table 1 Comparison of PRISMS and NINDS Studies ..... 18
    Table 2 NIHSS Exclusion Criteria of Recently Completed and Ongoing Acute Ischemic Stroke Trials ..... 22
    Table 3 Intracranial Hemorrhage Definitions ..... 25
    Table 4 Adverse Event Severity Grading Scale ..... 42
    Table 5 Causal Attribution Guidance ..... 43
    LIST OF FIGURES
    Figure 1 Study Schema ..... 20
    LIST OF APPENDICES
    Appendix 1 Schedule of Assessments ..... 62
    Appendix 2 Alteplase Administration ..... 65
    Appendix 3 Reconstitution of Vials ..... 66
    Appendix 4 European Quality of Life-5D (EQ-5D) Questionnaire ..... 67
    Appendix 5 Stroke Index Scale (SIS-16) ..... 69
    Appendix 6 Center for Epidemiologic Studies, Depression (CES-D) Scale, NIMH ..... 70
    Appendix 7 National Institutes of Health Stroke Scale (NIHSS) ..... 71
    Appendix 8 Modified Rankin Scale (mRS) ..... 75
    Appendix 9 Glasgow Outcome Scale (GOS) ..... 76
    Appendix 10 Barthel Index (BI) ..... 77
    Appendix 11 Cognitive Assessments ..... 79
    Appendix 1210 Meter Walk Test ..... 88
    Appendix 13 Preferred Terms for Intracranial Hemorrhage ..... 91
    Appendix 14 WHO Toxicity Grading Scale for Determining the Severity of Adverse Events ..... 92

PROTOCOL ACCEPTANCE FORM

A PHASE IIIb, DOUBLE-BLIND, MULTICENTER STUDY TO EVALUATE THE EFFICACY AND SAFETY OF ALTEPLASE IN PATIENTS WITH MILD STROKE: RAPIDLY IMPROVING SYMPTOMS AND MINOR NEUROLOGIC DEFICITS (PRISMS)

PROTOCOL SYNOPSIS

Objectives

Primary Objectives

Secondary Objectives

• To further evaluate efficacy of IV alteplase to improve mild stroke outcomes at Day 90 via:
• Ordinal improvement in mRS
• Neurological outcome (as measured by NIHSS 0-1)
• Independence in instrumental activities of daily (Barthel Index )
• Glasgow Outcome Scale (GOS) 0-1
• Global favorable recovery (Global Statistic with contributions from mRS 0-1, NIHSS 0-1, BI , and GOS 0-1)
• To evaluate safety as measured by:
• Symptomatic intracranial hemorrhage (sICH) within 36 hours - primary safety assessment
• Any intracranial hemorrhage (ICH) within 36 hours
• Mortality within 90 days
• Incidence, severity, and spectrum of all adverse events (AEs) and serious adverse events (SAEs)

Exploratory Objectives

• Stroke recurrence (based on AE monitoring) within 90 days
• Cognition ( 30 -minute assessment: animal naming, controlled oral word association test, digit symbol coding from the Wechsler Adult Intelligence Scale, Hopkins Verbal Learning Test, 15 -item Boston Naming Test, forward and backward Digit Span test, and Rey-Osterreith Complex Figure test) at Day 90
• Ambulatory performance (as measured by walking speed) at Day 90
• Depression (Center for Epidemiologic Studies, Depression [CES-D] score) at Day 90
• Quality of life (European Quality of Life [EQ-5D] questionnaire) at Day 90
• Stroke Impact Scale-16 (SIS-16) at Day 90

Study Design

Description of Study

Number of Patients

Target Population

Inclusion Criteria

• Age years (no upper age limit)
• Mild ischemic stroke defined as the most recent pre-treatment NIHSS score of and determined as not clearly disabling by the investigator. This includes patients with persistently mild deficits as well as those who improve to a pre-treatment NIHSS score (also known as RISS).
• Study treatment can be initiated within 3 hours of last known well time without stroke symptoms (i.e., last seen normal).
• Signed informed consent prior to initiation of any study-specific procedure or treatment. The patient or the patient's legally authorized representative must be able to provide written informed consent and understand the potential risks and benefits from study enrollment and treatment.

Exclusion Criteria

• Computed tomography (CT) or magnetic resonance imaging (MRI) findings consisting of one of the following:
• Clear large hypodensity on CT (or concurrent diffusion-weighted and fluid attenuated inversion recovery hyperintensity on MRI) that is greater than one-third middle cerebral artery (MCA) territory or greater than 100 cc if not in MCA territory
• Imaging lesion consistent with acute hemorrhage of any degree, OR
• Evidence of intraparenchymal tumor
• Disability (historical mRS score ) prior to the presenting stroke
• Standard contraindications to IV alteplase for patients treated within 3 hours of symptom onset, including:
• Head trauma or previous stroke within the previous 3 months
• Myocardial infarction within the previous 3 months
• Gastrointestinal or urinary tract hemorrhage within the previous 21 days
• Major surgery within the previous 14 days
• Arterial puncture at a non-compressible site within the previous 7 days
• Any history of ICH with the exception of chronic microbleeds on MRI
• Elevated blood pressure (systolic or diastolic ), or the use of aggressive measures (use of more than two intravenous agents to lower blood pressure) to achieve blood pressure within acceptable parameters
• Treatment with heparin within the last 48 hours and activated partial thromboplastin time outside of the normal range as specified by the center's local laboratory
• Blood glucose
• International normalized ratio (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Platelet count of (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (e.g., dabigatran, rivaroxaban, apixaban, edoxaban) within the last 48 hours
• Allergic reactions to study drug or aspirin
• Females of childbearing age who are known to be pregnant and/or lactating, or who have a positive pregnancy test on admission
• Inability to swallow, which would prevent oral intake of aspirin or aspirin placebo tablet
• Other serious, advanced, or terminal illness that would confound the clinical outcome at 90 days
• Current or recent (within 3 months) participation in another investigational drug treatment protocol
• Anticipated inability to obtain 3 -month follow-up assessments
• Previous enrollment in PRISMS
• Any other condition that the investigator feels would pose a significant hazard to the patient if treatment with alteplase is initiated

Length of Study

End of Study

Efficacy Outcome Measures

• A favorable functional outcome, defined by an mRS score of 0 or 1 at Day 90 post-randomization
• All mRS assessments will be made by investigators blinded to treatment assignment who are trained and certified in mRS administration

• Ordinal improvement in mRS
• Neurological outcome (as measured by NIHSS 0-1)
• Instrumental activities of daily living, as measured by the
• GOS 0-1
• Global outcome (Global Statistic with contributions from mRS 0-1, NIHSS 0-1, BI , and GOS 0-1)

Safety Outcome Measures

• Incidence of SICH within 36 hours (see below)
  sICH, defined as any neurological decline attributed to new ICH seen on imaging by the investigator and later confirmed on independent reading by blinded central study radiologists
• Any ICH within 36 hours
• Overall mortality within 90 days
• Stroke-related and neurological deaths
• Incidence, severity, and spectrum of all AEs and SAEs

Investigational Medicinal Products

Test Product

Comparator

Non-Investigational Medicinal Products

Comparator

Comparator

Statistical Methods

Primary Analysis

Determination of Sample Size

Interim Analysis

1. BACKGROUND

1.1 BACKGROUND ON ACUTE ISCHEMIC STROKE

1.2 BACKGROUND ON ALTEPLASE

1.2.1 Fibrinolysis and Tissue Plasminogen Activator

1.3 STUDY RATIONALE AND BENEFIT-RISK ASSESSMENT

Alteplase-Genentech, Inc.
Protocol ML29093, Version 1

2. OBJECTIVES

2.1 PRIMARY OBJECTIVES

2.2 SECONDARY OBJECTIVES

• To further evaluate efficacy of IV alteplase to improve mild stroke outcomes at Day 90 via:
• Ordinal improvement in mRS
• Neurological outcome (as measured by NIHSS 0-1)
• Independence in instrumental activities of daily (Barthel Index )
• Glasgow Outcome Scale (GOS) 0-1

Alteplase-Genentech, Inc.

• Global favorable recovery (Global Statistic with contributions from mRS 0-1, NIHSS 0-1, BI , and GOS 0-1)
• To evaluate safety as measured by:
• sICH within 36 hours - primary safety assessment
• Any ICH within 36 hours
• Mortality within 90 days
• Incidence, severity, and spectrum of all AEs and serious adverse events (SAEs)

2.3 EXPLORATORY OBJECTIVES

• Stroke recurrence (based on AE monitoring) within 90 days
• Cognition ( 30 -minute assessment: animal naming, controlled oral word association test, digit symbol coding from the Wechsler Adult Intelligence Scale, Hopkins Verbal Learning Test, 15 -item Boston Naming Test, forward and backward Digit Span test, and Rey-Osterreith Complex Figure test) at Day 90
• Ambulatory performance (as measured by walking speed) at Day 90
• Depression (Center for Epidemiologic Studies, Depression [CES-D] score) at Day 90
• Quality of life (European Quality of Life [EQ-5D] questionnaire) at Day 90
• Stroke Impact Scale-16 (SIS-16) at Day 90

3. STUDY DESIGN

3.1 DESCRIPTION OF STUDY

3.2 LENGTH OF STUDY

3.3 END OF STUDY

3.3.1 Number of Patients

3.4 RATIONALE FOR STUDY DESIGN

• Consistent with the currently approved indication in the alteplase USPI: Treatment with alteplase in PRISMS will occur in otherwise eligible AIS patients within 3 hours from the last known well time.
• Conduct of a large, multicenter study: The Sponsor plans to enroll 948 patients across approximately 75 sites in the U.S. and Canada (for comparison, the two NINDS trials enrolled a total of 624 patients).
• Multiple endpoints involving different events: In addition to the primary efficacy endpoint of mRS at Day 90, which measures disability, secondary endpoints at Day 90 will include the NIHSS score (neurologic deficit), BI (instrumental activities of daily living), GOS (disability), and a Global Statistic calculation.

3.4.1 Rationale for Alteplase Dosage

3.4.2 Rationale for Patient Population

1. An NIHSS score is commonly used as an exclusion criterion for many current AIS studies, suggesting that these patients are underrepresented in current stroke research and are treated differently by the stroke community, as shown in Table 2.

3.4.3 Rationale for Control Group

3.5 OUTCOME MEASURES

3.5.1 Efficacy Outcome Measures

• A favorable functional outcome, defined by an mRS score of 0 or 1 at Day 90 post-randomization
• All mRS assessments will be made by investigators blinded to treatment assignment who are trained and certified in mRS administration

• Ordinal improvement in mRS
• Neurological outcome (as measured by NIHSS 0-1)
• Instrumental activities of daily living, as measured by the
• GOS 0-1
• Global outcome (Global Statistic with contributions from mRS 0-1, NIHSS 0-1, BI , and GOS 0-1)

3.5.2 Safety Outcome Measures

• Incidence of sICH within 36 hours (see below)
• sICH, defined as any neurological decline attributed to new ICH seen on imaging by the investigator and later confirmed on independent reading by blinded central study radiologists
• Any ICH within 36 hours
• Overall mortality within 90 days
• Stroke-related and neurological deaths
• Incidence, severity, and spectrum of all AEs and SAEs

Symptomatic Intracranial Hemorrhage

3.5.3 Exploratory Outcome Measures

• Stroke recurrence (based on AE monitoring) within 90 days
• Cognition ( 30 -minute assessment: animal naming, controlled oral word association test, digit symbol coding from the Wechsler Adult Intelligence Scale, Hopkins Verbal Learning Test, 15 -item Boston Naming Test, forward and backward Digit Span test, and Rey-Osterreith Complex Figure test) at Day 90
• Ambulatory performance (as measured by walking speed) at Day 90
• Depression (CES-D score) at Day 90
• Quality of life (EQ-5D questionnaire) at Day 90
• SIS-16 at Day 90

4. MATERIALS AND METHODS

4.1 PATIENTS

4.1.1 Inclusion Criteria

• Age years (no upper age limit)
• Mild ischemic stroke defined as the most recent pre-treatment NIHSS score of and determined as not clearly disabling by the investigator. This includes patients with persistently mild deficits as well as those who improve to a pre-treatment NIHSS score (also known as RISS).
• Study treatment can be initiated within 3 hours of last known well time without stroke symptoms (i.e., last seen normal).
• Signed informed consent prior to initiation of any study-specific procedure or treatment. The patient or the patient's legally authorized representative must be able to provide written informed consent and understand the potential risks and benefits from study enrollment and treatment.

4.1.2 Exclusion Criteria

• CT or MRI findings consisting of one of the following:
• Clear large hypodensity on CT (or concurrent diffusion-weighted [DW] and fluid attenuated inversion recovery [FLAIR] hyperintensity on MRI) that is greater than one-third middle cerebral artery (MCA) territory or greater than 100 cc if not in MCA territory
• Imaging lesion consistent with acute hemorrhage of any degree, OR
• Evidence of intraparenchymal tumor
• Disability (historical mRS score ) prior to the presenting stroke
• Standard contraindications to IV alteplase for patients treated within 3 hours of symptom onset, including:
• Head trauma or previous stroke within the previous 3 months
• Myocardial infarction within the previous 3 months
• Gastrointestinal or urinary tract hemorrhage within the previous 21 days
• Major surgery within the previous 14 days
• Arterial puncture at a non-compressible site within the previous 7 days
• Any history of ICH with the exception of chronic microbleeds on MRI
• Elevated blood pressure (systolic or diastolic ), or the use of aggressive measures (use of more than two intravenous agents to lower blood pressure) to achieve blood pressure within acceptable parameters
• Treatment with heparin within the last 48 hours and activated partial thromboplastin time (aPTT) outside of the normal range as specified by the center's local laboratory
• Blood glucose
• International normalized ratio (INR) (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Platelet count of (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (e.g., dabigatran, rivaroxaban, apixaban, edoxaban) within the last 48 hours
• Allergic reactions to study drug or aspirin
• Females of childbearing age who are known to be pregnant and/or lactating, or who have a positive pregnancy test on admission
• Inability to swallow, which would prevent oral intake of aspirin or aspirin placebo tablet
• Other serious, advanced, or terminal illness that would confound the clinical outcome at 90 days
• Current or recent (within 3 months) participation in another investigational drug treatment protocol
• Anticipated inability to obtain 3 -month follow-up assessments
• Previous enrollment in PRISMS
• Any other condition that the investigator feels would pose a significant hazard to the patient if treatment with alteplase is initiated

4.2 METHOD OF TREATMENT ASSIGNMENT AND BLINDING

Step Forward Randomization

1. IxRS will assign a patient ID to the currently treated patient, which will be correlated to the drug kit ID previously labeled as "use next," via the randomization visit record.
2. IxRS will assign a new drug kit ID for the next patient that becomes eligible at that site to be labeled as "use next."

Study Unblinding

1. Patient must have an NIHSS score (or new clearly disabling deficit) measured twice within a 10 -minute span.
2. Patient's NIHSS increase must be points from the pre-treatment NIHSS (e.g., if a patient's pre-treatment NIHSS was 5 , the worsened NIHSS must be ).

4.3 STUDY TREATMENT

4.3.1 Formulation, Packaging, and Handling

4.3.1.1 Alteplase

4.3.1.2 Alteplase Placebo

4.3.1.3 Aspirin

4.3.1.4 Aspirin Placebo

4.3.2 Dosage, Administration, and Compliance

4.3.2.1 Alteplase

4.3.3 Investigational Medicinal Product Accountability

4.3.4 Investigational Medicinal Product

4.3.4.1 Alteplase and Placebo

Test Product

Comparator

4.3.4.2 Non-investigational Medicinal Products

Comparator

4.3.5 Post-Trial Access to Alteplase

4.4 CONCOMITANT THERAPY

4.4.1 Permitted Therapy

4.4.2 Prohibited Therapy

• Treatment with heparin within the last 48 hours and aPTT outside of the normal range as specified by the center's local laboratory
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (e.g., dabigatran, rivaroxaban, apixaban, edoxaban) within the last 48 hours
• Treatment with warfarin and INR>1.7

4.5 STUDY ASSESSMENTS

4.5.1 Description of Study Assessments

4.5.1.1 Informed Consent Forms and Screening Log

4.5.1.2 Medical History and Demographic Data

4.5.1.3 Neurological Examinations

4.5.1.4 Vital Signs

4.5.1.5 Laboratory Assessments

• Platelet count
• Serum glucose
• Coagulation (INR, aPTT) if a patient is currently taking oral or parenteral anticoagulants
• Pregnancy test (serum or urine)

• Hematology (hemoglobin, hematocrit, white blood cell count, platelet count)
• Serum glucose
• Coagulation values (INR, partial thromboplastin time)
• Pregnancy test

4.5.1.6 Other Disease-Specific Assessments

4.5.2 Patient-Reported Outcomes

4.6 TIMING OF STUDY ASSESSMENTS

4.6.1 Screening/Baseline (Visit 1)

• Medical history
• Demographics
• Neurological examination
• Vital signs
• Complete blood count
• Coagulation status
• Pregnancy test (serum or urine)
• Serum blood glucose
• Non-contrast CT scan or MRI, including DW MRI, either SW or GRE, and FLAIR images
• NIHSS score (This must be performed by an NIHSS-certified practitioner see Appendix 7.
• Concomitant medications
• AEs

4.6.2 Visit 2 (22 to Hours after Treatment Initiation)

4.6.3 Visit 3 (Day 5 or Discharge from Hospital, if Sooner than Day 5)

4.6.4 Visit 4 (Day Days])

4.6.5 Visit 5 (Day Days]/Study Completion)

• NIHSS score (Appendix 7)
• Patient survival
• mRS (Appendix 8)
• GOS (Appendix 9
• BI (Appendix 10)
• EQ-5D (Appendix 4)
• SIS-16 (Appendix 5)
• CES-D (Appendix 6)
• Cognitive assessments (Appendix 11)
• Animal Naming test
• Controlled Oral Word Association test
• Digit symbol coding from the Wechsler Adult Intelligence Scale
• Hopkins Verbal Learning test
• 15-item Boston Naming test
• Forward and Backward Digit Span test
• Rey-Osterrieth Complex Figure test
• Walking speed (Appendix 12)
• Concomitant medications
• AEs

4.6.6 Early Discontinuation

4.7 PATIENT, TREATMENT, STUDY, AND SITE DISCONTINUATION

4.7.1 Patient Discontinuation

• Patient withdrawal of consent at any time
• Any medical condition that the investigator or Sponsor determines may jeopardize the patient's safety if he or she continues in the study
• Investigator or Sponsor determines it is in the best interest of the patient
• Patient non-compliance, specifically defined as unwillingness to participate in a 3-month assessment of neurological status and function

4.7.2 Study Treatment Discontinuation

• Anaphylactoid reaction (including angioedema)
• Serious bleeding (not controllable by local pressure) at puncture site or serious bleeding in a critical location (e.g., intracranial, gastrointestinal, retroperitoneal, pericardial)

Alteplase-Genentech, Inc.
Protocol ML29093, Version 1

4.7.3 Study and Site Discontinuation

• The incidence or severity of AEs in this or other studies indicates a potential health hazard to patients.
• Patient enrollment is unsatisfactory
• A pre-specified boundary at the interim analysis was crossed

• Excessively slow recruitment
• Poor protocol adherence
• Inaccurate or incomplete data recording
• Non-compliance with the International Conference on Harmonisation guideline for Good Clinical Practice
• No study activity (i.e., all patients have completed study assessments and all obligations have been fulfilled)

5. ASSESSMENT OF SAFETY

5.1 SAFETY PLAN

5.1.1 Risk of Bleeding

Management of Bleeding

5.1.2 Risk of Allergic Reactions

Management of Allergic Reaction

5.2 SAFETY PARAMETERS AND DEFINITIONS

5.2.1 Adverse Events

• Any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal product, whether or not considered related to the medicinal product
• Any new disease or exacerbation of an existing disease (a worsening in the character, frequency, or severity of a known condition), except as described in Section 5.3.3.9
• Recurrence of an intermittent medical condition (e.g., headache) not present at baseline
• Any deterioration in a laboratory value or other clinical test (e.g., electrocardiogram, X-ray) that is associated with symptoms or leads to a change in study treatment or concomitant treatment or discontinuation from study drug
• AEs that are related to a protocol-mandated intervention, including those that occur prior to assignment of study treatment (e.g., screening invasive procedures such as biopsies)

5.2.2 Serious Adverse Events (Immediately Reportable to the Sponsor)

• Fatal (i.e., the AE actually causes or leads to death)
• Life-threatening (i.e., the AE, in the view of the investigator, places the patient at immediate risk of death)

• Requires or prolongs inpatient hospitalization (see Section 5.3.3.9)
• Results in persistent or significant disability/incapacity (i.e., the AE results in substantial disruption of the patient's ability to conduct normal life functions)
• Congenital anomaly/birth defect in a neonate/infant born to a mother exposed to study drug
• Significant medical event in the investigator's judgment (e.g., may jeopardize the patient or may require medical/surgical intervention to prevent one of the outcomes listed above)

5.2.3 Non-Serious Adverse Events of Special Interest (Immediately Reportable to the Sponsor)

• All events of sICH (use a list of preferred terms [PTs] see Appendix 13)
• In addition, Suspected Transmission of an Infectious Agent via a Medicinal Product (STIAMP) by the study drug in a Genentech-sponsored trial qualifies as an AESI and requires immediate reporting to the Sponsor.

5.3 METHODS AND TIMING FOR CAPTURING AND ASSESSING SAFETY PARAMETERS

5.3.1 Adverse Event Reporting Period

5.3.2 Assessment of Severity of Adverse Events

5.3.3 Assessment of Causality of Adverse Events

• Temporal relationship of event onset to the initiation of study drug
• Course of the event, considering especially the effects of dose reduction, discontinuation of study drug, or reintroduction of study drug (as applicable)
• Known association of the event with the study drug or with similar treatments
• Known association of the event with the disease under study
• Presence of risk factors in the patient or use of concomitant medications known to increase the occurrence of the event
• Presence of non-treatment-related factors that are known to be associated with the occurrence of the event

5.3.3.1 Diagnosis versus Signs and Symptoms

5.3.3.2 Adverse Events Occurring Secondary to Other Events

• If vomiting results in mild dehydration with no additional treatment in a healthy adult, only vomiting should be reported on the eCRF.
• If vomiting results in severe dehydration, both events should be reported separately on the eCRF.
• If a severe gastrointestinal hemorrhage leads to renal failure, both events should be reported separately on the eCRF.
• If dizziness leads to a fall and consequent fracture, all three events should be reported separately on the eCRF.
• If neutropenia is accompanied by an infection, both events should be reported separately on the eCRF.

5.3.3.3 Persistent or Recurrent Adverse Events

5.3.3.4 Abnormal Laboratory Values

• Accompanied by clinical symptoms
• Results in a change in study treatment (e.g., dosage modification, treatment interruption, or treatment discontinuation)
• Results in a medical intervention (e.g., potassium supplementation for hypokalemia) or a change in concomitant therapy
• Clinically significant in the investigator's judgment

5.3.3.5 Abnormal Vital Sign Values

• Accompanied by clinical symptoms
• Results in a change in study treatment (e.g., dosage modification, treatment interruption, or treatment discontinuation)
• Results in a medical intervention or a change in concomitant therapy
• Clinically significant in the investigator's judgment

5.3.3.6 Deaths

5.3.3.7 Preexisting Medical Conditions

5.3.3.8 Lack of Efficacy or Worsening of Acute Ischemic Stroke

5.3.3.9 Hospitalization or Prolonged Hospitalization

• Hospitalization for respite care
• Hospitalization for a preexisting condition, provided that all of the following criteria are met:
• The hospitalization was planned prior to the study or was scheduled during the study when elective surgery became necessary because of the expected normal progression of the disease.
• The patient has not suffered an AE.

5.3.3.10 Adverse Events Associated with an Overdose

5.3.3.11 Patient-Reported Outcome Data

5.4 IMMEDIATE REPORTING REQUIREMENTS FROM INVESTIGATOR TO SPONSOR

• SAEs
• Non-serious AESI
• Pregnancies

• New signs or symptoms or a change in the diagnosis
• Significant new diagnostic test results
• Change in causality based on new information
• Change in the event's outcome, including recovery
• Additional narrative information on the clinical course of the event

5.4.1 Emergency Medical Contacts

5.4.2 Reporting Requirements for Serious Adverse Events and Non-Serious Adverse Events of Special Interest

5.4.3 Reporting Requirements for Pregnancies

5.4.3.1 Pregnancies in Female Patients

5.4.3.2 Congenital Anomalies/Birth Defects and Abortions

5.5 FOLLOW-UP OF PATIENTS AFTER ADVERSE EVENTS

5.5.1 Investigator Follow-Up

5.5.2 Sponsor Follow-Up

5.6 POST-STUDY ADVERSE EVENTS

5.7 EXPEDITED REPORTING TO HEALTH AUTHORITIES, INVESTIGATORS, INSTITUTIONAL REVIEW BOARDS, AND ETHICS COMMITTEES

• Alteplase Investigator's Brochure

6. STATISTICAL METHODS

6.1 DETERMINATION OF SAMPLE SIZE

6.2 PRIMARY ANALYSIS

6.3 SAFETY ANALYSIS

6.4 EXPLORATORY ANALYSES

• Age (<65 vs. )
• Pre-treatment NIHSS score (0-2 vs. 3-5)
• Last known well time to treatment ( vs. hours)
• Stroke subgroup (RISS vs. non-RISS)

6.5 INTERIM ANALYSIS

6.6 MISSING DATA HANDLING

7. DATA COLLECTION AND MANAGEMENT

7.1 DATA QUALITY ASSURANCE

7.2 ELECTRONIC CASE REPORT FORMS

7.3 SOURCE DATA DOCUMENTATION

7.4 USE OF COMPUTERIZED SYSTEMS

7.5 RETENTION OF RECORDS

8. ETHICAL CONSIDERATIONS

8.1 COMPLIANCE WITH LAWS AND REGULATIONS

8.2 INFORMED CONSENT

8.3 INSTITUTIONAL REVIEW BOARD OR ETHICS COMMITTEE

8.4 CONFIDENTIALITY

8.5 FINANCIAL DISCLOSURE

9.1 STUDY DOCUMENTATION

9.2 PROTOCOL VIOLATIONS

9.3 SITE INSPECTIONS

9.4 ADMINISTRATIVE STRUCTURE

• Provide recommendations regarding changes in the study conduct
• Review results of the final analyses for primary and secondary endpoints
• Participate in the drafting and publishing of final study results

• Review all accumulated safety data at interim analysis
• Review efficacy data analysis performed for interim analysis for consideration of potential discontinuation of the trial for futility
• Make recommendation to the Sponsor as to if it is appropriate to discontinue the study after assessing the interim efficacy and safety data in aggregate
• Determine if the study should continue after review of interim analysis results and to assess the sample size requirement using accumulated data, as described in the protocol

9.5 PROTOCOL AMENDMENTS

10. REFERENCES

Alteplase-Genentech, Inc.

Appendix 1 (cont.)
Schedule of Assessments

Appendix 1 (cont.) Schedule of Assessments

Appendix 2
Alteplase Administration

Administration of bolus

Appendix 3
Reconstitution of Vials

Step 1:

Step 2:

Step 3:

Step 4:

Step 5:

Appendix 4
European Quality of Life-5D (EQ-5D) Questionnaire

Pain/Discomfort

Anxiety/Depression

Appendix 4 （cont．）
European Quality of Life－5D（EQ－5D）Questionnaire

Appendix 6
Center for Epidemiologic Studies, Depression (CES-D) Scale, NIMH

Appendix 7

National Institutes of Health Stroke Scale (NIHSS)

Appendix 7 (cont.) National Institutes of Health Stroke Scale (NIHSS)

Appendix 7 (cont.)

National Institutes of Health Stroke Scale (NIHSS)

Appendix 7 (cont.) National Institutes of Health Stroke Scale (NIHSS)

Appendix 8
Modified Rankin Scale (mRS)

Appendix 9 Glasgow Outcome Scale (GOS)

References

Appendix 10
Barthel Index (BI)

Appendix 10 (cont.) Barthel Index (BI)

The Barthel ADL Index: Guidelines

1. The index should be used as a record of what a patient does, not as a record of what a patient could do.
2. The main aim is to establish degree of independence from any help, physical or verbal, however minor and for whatever reason.
3. The need for supervision renders the patient not independent.
4. A patient's performance should be established using the best available evidence. Asking the patient, fiiends/relatives and nurses are the usual sources, but direct observation and common sense are also important. However direct testing is not needed.
5. Usually the patient's performance over the preceding hours is important, but occasionally longer periods will be relevant.
6. Middle categories imply that the patient supplies over 50 per cent of the effort.
7. Use of aids to be independent is allowed.

Appendix 11
Cognitive Assessments

A. Animal Naming Test

DIRECTIONS

1. State, "I would like to name as many animals as you can think of in one minute. I will tell you when to start and stop. Do you understand the directions?"
2. Tell the patient to start naming animals. Write down the animal names below in the order stated. Any kind of animal is acceptable. Write down repeated animals, but do not score those. After one minute, tell the patient to stop.
3. Scoring: Count each unique animal listed.

List of Animals:

B. Controlled Oral Word Association Test

Appendix 11 (cont.) Cognitive Assessments

Appendix 11 (cont.) Cognitive Assessments

Appendix 11 (cont.) Cognitive Assessments

D. Hopkins Verbal Learning Test (Brandt 1991)

Appendix 11 (cont.) Cognitive Assessments

E. Boston Naming Test (BNT)

• Total words tried □ . □

Appendix 11 (cont.) Cognitive Assessments

F. Forward and Backward Digit Span Test

DIGIT SPAN (FORWARD)*

DIGIT SPAN (BACKWARD)*

Appendix 11 (cont.) Cognitive Assessments

G. Rey-Osterrieth Complex Figure Test

Copy Trial

-

• 14
  
  14 Diamond attached to (13)
  
  15 Verticle line within triangle (13), parallel to the right side of (2)
  

16. Horizontal line within (13), conlinuing (4) to the right
    
17. Cross attached to lower center

Absent or not recognizable

Appendix 11 (cont.) Cognitive Assessments

Please draw the figure below on the blank half-sheet that was given to you:

Appendix 12
10 Meter Walk Test

Physical Assistance Provided During Testing:

Test Administration:

1. Instruct the subject in the goal of the 10 meter walk test while the subject is seated:
   "You are going to walk a distance of about feet. We will repeat this distance four times. The first two times will be completed at your comfortable pace, the final two times you will walk as quickly and safely as you can. Do you have any questions?"
2. Demonstrate where you want the subject to walk.
3. Walk the subject to the start line (0 meters). Provide the subject with the following instructions:
   "You will walk at a comfortable pace to the chair." (DO NOT refer to the tape on the floor.) The start command is "Ready and Go".
4. When you and the subject are ready, say "Ready and Go". If the subject starts too early, start again.

Appendix 12 (cont.) 10 Meter Walk Test

5. Instructions for Recording Time:
   □ START the stopwatch when the subject's first foot crosses the plane of the 2 meter line
   □ STOP the stopwatch when the subject's first foot crosses the plane of the 12 meter line.
   □ Have the subject continue walking until he/she reaches the chair after the 14 meter line.
   □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance
   "Comfortable" Pace Trial 1 line on the 10 Meter Walk Test Source Document.
   □ The subject can rest, if needed, in the chair near the 14 meter line.
6. When the subject is ready, have them repeat the SAME PROCEDURE except they will start from the 14 meter line and end at 0 meter line.
   □ START the stopwatch when the subject's first foot crosses the plane of the 12 meter line
   □ STOP the stopwatch when the subject's first foot crosses the plane of the 2 meter line.
   □ Have the subject continue walking until he/she reaches the chair after the 0 meter line.
   □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance on the "Comfortable" Pace Trial 2 line on the 10 Meter Walk Test Source Document.
   □ The subject can rest, if needed, in the chair near the 0 meter line.
7. Subject Instructions for the last 2 trials:
   "You are going to walk the same distances for two additional trials as quickly and as safely as you can. Do you have any questions?"
8. When the subject is ready, walk the subject to the start line ( 0 meters). Provide the subject with the following instructions:
   "You will walk as quickly and as safely as you can to the chair." (Use an appropriate descriptor for chair/location, but DO NOT refer to the tape on the floor.) The start command is "Ready and Go".
9. When you and the subject are ready, say "Ready and Go". If the subject starts too early, have them start again.

Appendix 12 (cont.) 10 Meter Walk Test

10. Instructions for Recording Time:
    □ START the stopwatch when the subject's first foot crosses the plane of the 2 meter line
    □ STOP the stopwatch when the subject's first foot crosses the plane of the 12 meter line.
    □ Have the subject continue walking until he/she reaches the chair after the 14 meter line.
    □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance on the "As Fast As Possible" Pace Trial 1 line on the 10 Meter Walk Test Source Document.
    □ The subject can rest, if needed, in the chair near the 14 meter line.
11. When the subject is ready, have them repeat the SAME PROCEDURE except they will start from the 14 meter line and end at 0 meter line.
    □ START the stopwatch when the subject's first foot crosses the plane of the 12 meter line
    □ STOP the stopwatch when the subject's first foot crosses the plane of the 2 meter line.
    □ Have the subject continue walking until he/she reaches the chair after the 0 meter line.
    □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance on the "As Fast As Possible" Pace Trial 2 line on the 10 Meter Walk Test Source Document.
    □ The subject can rest, if needed, in the chair near the 0 meter line.
12. Record the assistive device used and the Functional Ambulation Category (FAC) on the 10 Meter Walk Test Source Document.

REFERENCES:

Appendix 13

Preferred Terms for Intracranial Hemorrhage

• Basal ganglia hemorrhage
• Brain stem hematoma
• Brain stem hemorrhage
• Brain stem microhemorrhage
• Central nervous system hemorrhage
• Cerebellar hematoma
• Cerebellar hemorrhage
• Cerebellar microhemorrhage
• Cerebral arteriovenous malformation hemorrhagic
• Cerebral hematoma
• Cerebral hemorrhage
• Cerebral microhemorrhage
• Extradural hematoma
• Hemorrhage intracranial
• Hemorrhagic cerebral infarction
• Hemorrhagic stroke
• Hemorrhagic transformation stroke
• Intracranial hematoma
• Intraventricular hemorrhage
• Meningorrhagia
• Pituitary hemorrhage
• Purpura cerebri
• Putamen hemorrhage
• Subarachnoid hemorrhage
• Subdural hematoma
• Subdural hemorrhage
• Thalamus hemorrhage
• Traumatic intracranial hemorrhage

Appendix 14

WHO Toxicity Grading Scale for Determining the Severity of Adverse Events

Appendix 14 (cont.)
WHO Toxicity Grading Scale for Determining the Severity of Adverse Events

Appendix 14 (cont.)
WHO Toxicity Grading Scale for Determining the Severity of Adverse Events

Appendix 14 (cont.)

WHO Toxicity Grading Scale for Determining the Severity of Adverse Events

PROTOCOL

PROTOCOL APPROVAL

Approver's Name

Title

CONFIDENTIAL STATEMENT

Alteplase-Genentech, Inc.

PROTOCOL AMENDMENT, VERSION 2: RATIONALE

• Information was added to clarify that IV alteplase and alteplase placebo may not be initiated beyond 3 hours of last known well time under any circumstances.
• Instructions were added to allow sites to administer oral aspirin/aspirin placebo up to 24 hours after last known well time (instead of within 3 hours of last known well time) if a site has institutional policies on oral medications that make it challenging to administer oral study drug within 3 hours of last known well time.
• Changes were made to ensure that the language "not clearly disabling" is consistent throughout the protocol.
• A change was made to the adverse event (AE)/serious adverse event (SAE) collection time from screening/baseline to study drug administration.
• The non-serious AE collection period was reduced to 30 days (with the exception of intracranial hemorrhage, adverse events of special interest (AESIs), and AEs leading to study withdrawal) to better align with other acute stroke studies involving alteplase and to reduce the burden of AE collection at the Day 90 visit in order to minimize missing data.
• The following exclusion criteria were updated to include:
• Treatment with unfractionated heparin within the last 48 hours and activated partial thromboplastin time outside of the normal range as specified by the center's local laboratory
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (including novel oral anticoagulants (e.g., dabigatran, rivaroxaban, apixaban, edoxaban) within the last 48 hours
• Treatment with a low-molecular-weight heparin (e.g., dalteparin, enoxaparin) within the last 48 hours
• Computed tomography (CT) or magnetic resonance imaging (MRI) findings consisting of one of the following:

PROTOCOL AMENDMENT, VERSION 2: SUMMARY OF CHANGES

GLOBAL CHANGES

PROTOCOL SYNOPSIS

SECTION 1.1: BACKGROUND ON ACUTE ISCHEMIC STROKE

TABLE 1: Comparison of PRISMS and NINDS Studies

SECTION 2.2: SECONDARY OBJECTIVES

• To further evaluate efficacy of IV alteplase to improve mild stroke outcomes at Day 90 via:
• Ordinal improvement in-mRS
• Neurological outcome (as measured by NIHSS 01 )
• Independence in instrumental activities of daily (Barthel Index )
• Glasgow Outcome Scale (GOS) 0-1
• Global favorable recovery (Global Statistic with contributionsOutcome Measure derived from mRS 0-1, NIHSS 0-1, Barthel Index , and Glasgow Outcome Scale [GOS] = 1)
  To evaluate safety as measured by:
  Stroke-related and neurological deaths within 90 days

SECTION 2.3: EXPLORATORY OBJECTIVES

• NIHSS
• BI
• GOS
• Cognition fand behavior (modified 30-minute assessment: animal naming,battery: Controlled Oral Word Association test-; Hopkins Verbal Learning Test-Revised [HVLT-R] trials 1, 2, and 3; digit symbol coding from the Wechsler Adult Intelligence Scale,Hopkins Verbal Learning Test, 15 item Boston Naming Test, III [WAIS III]; Forward and Backward Digit Span test, and Rey Osterreith Complex Figure; Benton Judgment of Line Orientation test), form V; HVLT-R trial 4 and recognition; semantic fluency [Animal Naming test]; Boston Naming Test [BNT; 15-item short form]) at Day 90
• Center for Epidemiologic Studies-Depression (CES-D)score) at Day 90

SECTION 3.1: DESCRIPTION OF STUDY

1. One dose of alteplase IV (not to exceed 90 mg ) and one dose of oral aspirin placebo, OR
2. One dose of IV alteplase placebo and one dose of oral aspirin 325 mg (Figure 1).

SECTION 3.3.1: Number of Patients

SECTION 3.4: RATIONALE FOR STUDY DESIGN

• Conduct of a large, multicenter study: The Sponsor plans to enroll 948 patients across approximately 75 sites in the U.S. and CanadaNorth America. (For comparison, the two NINDS trials enrolled a total of 624 patients.)
• Multiple endpoints involving different events: In addition to the primary efficacy endpoint of mRS at Day 90, which measures disability, secondary endpoints at Day 90 will include the NIHSS score (neurologic deficit), BI (instrumental activities of daily living), GOS (disability), and a Global Statistic calculationan ordinal mRS assessment and global favorable recovery, as calculated using the Global Outcome Measure derived from the mRS, NIHSS, BI, and GOS.

SECTION 3.4.1: Rationale for Alteplase Dosage

SECTION 3.4.2: Rationale for Patient Population

SECTION 3.5.1: Efficacy Outcome Measures

• Ordinal improvementin-mRS
• Neurological outcome (as measured by NIHSS 0-1)

• Instrumental activities of daily living, as measured by the
• Global outcomefavorable recovery (Global Statistic with contributionsOutcome Measure derived from mRS 0-1, NIHSS 0-1, BI , and GOS- )

SECTION 3.5.2: Safety Outcome Measures

• Incidence of sICH within 36 hours (primary safety assessment)
  sICH is defined as any neurological decline attributed to new ICH seen on imaging by the investigator-and. New ICH seen on imaging will be later confirmed on independent reading by blinded central study radiologists.
• Stroke-related and neurological deaths within 90 days

Symptomatic Intracranial Hemorrhage

TABLE 3: IntracranialIntracerebral Hemorrhage Definitions

SECTION 3.5.3: Exploratory Outcome Measures

• NIHSS at Day 90
• Instrumental activities of daily living, as measured by the BI at Day 90
• GOS at Day 90
• Cognition fand behavior (modified 30-minute assessment: animal naming,battery: Controlled Oral Word Association test,; Hopkins Verbal Learning Test-Revised [HVLT-R] trials 1, 2, and 3; digit symbol coding from the Wechsler Adult Intelligence Scale,Hopkins Verbal Learning Test, 15 item Boston Naming Test, III [WAIS III]; Forward and Backward Digit Span test, and Rey Osterreith Complex Figure; Benton Judgment of Line Orientation test), form V; HVLT-R trial 4 and recognition; semantic fluency [Animal Naming test]; Boston Naming Test [BNT 15-item short form]) at Day 90

SECTION 4.1.2: Exclusion Criteria

• CT or MRI findings consisting of one of the following:
• CT with clear large hypodensity on CT (or-that is greater than one-third middle cerebral artery (MCA) territory (or greater than 100 cc if not in MCA territory),
• MRI with clear large hyperintensity on concurrent diffusion-weighted (DW) and fluid-attenuated inversion recovery (FLAIR] hyperintensity on MRI) that is greater than one-third MCA territory (or greater than 100 cc if not in MCA territory),
• Disability (historical mRS score )-prior to the presenting stroke (historical score )
• Standard contraindications to IV alteplase for patients treated within 3 hours of symptom onset, including:
• Treatment with unfractionated heparin within the last 48 hours and activated partial thromboplastin time (aPTT) outside of the normal range as specified by the center's local laboratory
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (including novel oral anticoagulants [e.g., dabigatran, rivaroxaban, apixaban, edoxaban]) within the last 48 hours
• Treatment with a low-molecular-weight heparin (e.g., dalteparin, enoxaparin) within the last 48 hours

SECTION 4.2: METHOD OF TREATMENT ASSIGNMENT AND BLINDING

Study Unblinding

1. Patient must have an NIHSS score (or new clearly disabling deficit) measured twice within a 10 minute span.
2. Patient's NIHSS increase must be points from the pre treatment NIHSS (e.g., if a patient's pre treatment NIHSS was 5 , the worsened NIHSS must be ).

SECTION 4.3.2.1: Alteplase

SECTION 4.3.4.2: Non-investigational Medicinal Products

Comparator

SECTION 4.3.5: Post-Trial Access to Alteplase

SECTION 4.4.2: Prohibited Therapy

• Treatment with unfractionated heparin within the last 48 hours and aPTT outside of the normal range as specified by the center's local laboratory
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (including novel oral anticoagulants [e.g., dabigatran, rivaroxaban, apixaban, edoxaban]) within the last 48 hours
• Treatment with a low-molecular-weight heparin (e.g., dalteparin, enoxaparin) within the last 48 hours
• Treatment with warfarin and INR (Note: INR does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)

SECTION 4.5.1.1: Informed Consent Forms and Screening Log

SECTION 4.5.1.4: Vital Signs

SECTION 4.5.1.5: Laboratory Assessments

• PlateletComplete blood count without differential
• Coagulation (INR, aPTT) if a patient is currently taking oral or parenteral anticoagulants-
• Pregnancy test (serum or urine) for women of childbearing potential (including those who have had a tubal ligation) must have a serum pregnancy test at screening.

• Hematology (hemoglobin, hematocrit, whiteComplete blood cell-count, platelet count) without differential
• Coagulation values (INR, partial thromboplastin time)aPTT)
• Pregnancy test for women of childbearing potential including those who have had a tubal ligation

SECTION 4.5.1.6: Other Disease-Specific Assessments

SECTION 4.5.2: Patient-Reported Outcomes

SECTION 4.6.1: Screening/Baseline (Visit 1)

• Complete blood count without differential
• AEs

SECTION 4.6.2: Visit 2 (22 to 36 Hours after Treatment Initiation)

SECTION 4.6.3: Visit 3 (Day 5 or Discharge from Hospital, if Sooner than Day 5)

SECTION 4.6.4: Visit 4 (Day Days])

SECTION 4.6.5: Visit 5 (Day Days]/Study Completion)

• Cognitive assessments (Appendix 11)
• Animal Naming test

• HVLT-R trials 1, 2, and 3
• Hopkins Verbal Learning test
• 15 item Boston Naming test
• Rey Osterrieth Complex Figure test
• Benton Judgment of Line Orientation test, form V
• HVLT-R trial 4 and recognition
• Animal Naming test
• BNT 15-item short form

• AEs
• SAEs and certain AEs (See Section 5.3.1)

SECTION 4.7.2: Study Treatment Discontinuation

SECTION 5.2.1: Adverse Events

• AEs that are related to a protocol mandated intervention, including those that occur prior to assignment of study treatment (e.g., screening invasive procedures such as biopsies)

SECTION 5.2.3: Non-Serious Adverse Events of Special Interest (Immediately Reportable to the Sponsor

• AllsICH events, of sICH (use if not already reported as an SAE (for a list of preferred terms for ICH see Appendix 13)
• Stroke recurrence: report if the resulted in a substantial disruption of a person's ability to conduct normal life functions (i.e., the AE resulted in a significant, persistent, or permanent change; impairment; or damage or disruption in the patient's body function/structure, physical activities, and/or quality of life.

SECTION 5.3.1: Adverse Event Reporting Period

• All SAEs
• Non-serious ICHs
• Non-serious AESIs
• All AEs that resulted in withdrawal from the study

SECTION 5.3.3.8: Lack of Efficacy or Worsening of Acute Ischemic Stroke

SECTION 5.4.1: Emergency Medical Contacts

SECTION 5.6: POST-STUDY ADVERSE EVENTS

SECTION 6.1: DETERMINATION OF SAMPLE SIZE

SECTION 6.2: PRIMARY ANALYSIS

SECTION 6.3: SAFETY ANALYSIS

SECTION 6.4: EXPLORATORY ANALYSES

• Last known well time to treatment ( vs. hours)

SECTION 6.5: INTERIM ANALYSIS

Alteplase-Genentech, Inc.

SECTION 6.6: MISSING DATA HANDLING

SECTION 9.4: ADMINISTRATIVE STRUCTURE

• Determine if the study should continue after review of interim analysis results and to assess the sample size requirement using accumulated data, as described in the protocol

SECTION 10: REFERENCES

APPENDIX 1: Schedule of Assessments

APPENDIX 11: Cognitive and Behavioral Assessments

APPENDIX 13: Preferred Terms for Intracranial Hemorrhage

• Central nervous system hemorrhage
• Epidural hemorrhage
• Purpura cerebri

TABLE OF CONTENTS

1. BACKGROUND ..... 29
   1.1 Background on Acute Ischemic Stroke ..... 29
   1.2 Background on Alteplase ..... 29
   1.2.1 Fibrinolysis and Tissue Plasminogen Activator ..... 29
   1.3 Study Rationale and Benefit-Risk Assessment ..... 30
2. OBJECTIVES ..... 32
   2.1 Primary Objective ..... 32
   2.2 Secondary Objectives ..... 32
   2.3 Exploratory Objectives ..... 33
3. STUDY DESIGN ..... 33
   3.1 Description of Study ..... 33
   3.2 Length of Study ..... 35
   3.3 End of Study ..... 35
   3.3.1 Number of Patients ..... 35
   3.4 Rationale for Study Design ..... 35
   3.4.1 Rationale for Alteplase Dosage ..... 35
   3.4.2 Rationale for Patient Population ..... 36
   3.4.3 Rationale for Control Group ..... 38
   3.5 Outcome Measures ..... 38
   3.5.1 Efficacy Outcome Measures ..... 38
   3.5.2 Safety Outcome Measures ..... 39
   3.5.3 Exploratory Outcome Measures ..... 40
4. MATERIALS AND METHODS ..... 40
   4.1 Patients ..... 40
   4.1.1 Inclusion Criteria ..... 40
   4.1.2 Exclusion Criteria ..... 41
   4.2 Method of Treatment Assignment and Blinding ..... 42
   Alteplase-Genentech, Inc.
   Protocol ML29093, Version 2 ..... 16
   4.3 Study Treatment ..... 43
   4.3.1 Formulation, Packaging, and Handling ..... 43
   4.3.1.1 Alteplase ..... 43
   4.3.1.2 Alteplase Placebo ..... 44
   4.3.1.3 Aspirin ..... 44
   4.3.1.4 Aspirin Placebo ..... 44
   4.3.2 Dosage, Administration, and Compliance ..... 44
   4.3.2.1 Alteplase ..... 44
   4.3.3 Investigational Medicinal Product Accountability ..... 45
   4.3.4 Investigational Medicinal Product ..... 46
   4.3.4.1 Alteplase and Placebo ..... 46
   4.3.4.2 Non-investigational Medicinal Products ..... 46
   4.3.5 Post-Trial Access to Alteplase ..... 46
   4.4 Concomitant Therapy ..... 46
   4.4.1 Permitted Therapy ..... 46
   4.4.2 Prohibited Therapy ..... 46
   4.5 Study Assessments ..... 47
   4.5.1 Description of Study Assessments ..... 47
   4.5.1.1 Informed Consent Forms and Screening Log ..... 47
   4.5.1.2 Medical History and Demographic Data ..... 47
   4.5.1.3 Neurological Examinations ..... 47
   4.5.1.4 Vital Signs ..... 48
   4.5.1.5 Laboratory Assessments ..... 48
   4.5.1.6 Other Disease-Specific Assessments ..... 48
   4.5.2 Patient-Reported Outcomes ..... 49
   4.6 Timing of Study Assessments ..... 50
   4.6.1 Screening/Baseline (Visit 1) ..... 50
   4.6.2 Visit 2 (22 to 36 Hours after Treatment Initiation) ..... 50
   4.6.3 Visit 3 (Day 5 or Discharge from Hospital, if Sooner than Day 5) ..... 51
   4.6.4 Visit 4 (Day 30 [30 ± 7 Days]) ..... 51
   4.6.5 Visit 5 (Day Days]/Study Completion) ..... 51
   4.6.6 Early Discontinuation ..... 52
   4.7 Patient, Treatment, Study, and Site Discontinuation ..... 52
   4.7.1 Patient Discontinuation ..... 52
   4.7.2 Study Treatment Discontinuation ..... 52
   4.7.3 Study and Site Discontinuation ..... 53
5. ASSESSMENT OF SAFETY ..... 53
   5.1 Safety Plan ..... 53
   5.1.1 Risk of Bleeding ..... 54
   5.1.2 Risk of Allergic Reactions ..... 54
   5.2 Safety Parameters and Definitions ..... 54
   5.2.1 Adverse Events ..... 55
   5.2.2 Serious Adverse Events (Immediately Reportable to the Sponsor) ..... 55
   5.2.3 Non-Serious Adverse Events of Special Interest (Immediately Reportable to the Sponsor) ..... 56
   5.3 Methods and Timing for Capturing and Assessing Safety Parameters ..... 56
   5.3.1 Adverse Event Reporting Period ..... 56
   5.3.2 Assessment of Severity of Adverse Events ..... 57
   5.3.3 Assessment of Causality of Adverse Events ..... 57
   5.3.3.1 Diagnosis versus Signs and Symptoms ..... 58
   5.3.3.2 Adverse Events Occurring Secondary to Other Events ..... 59
   5.3.3.3 Persistent or Recurrent Adverse Events ..... 59
   5.3.3.4 Abnormal Laboratory Values ..... 59
   5.3.3.5 Abnormal Vital Sign Values ..... 60
   5.3.3.6 Deaths ..... 61
   5.3.3.7 Preexisting Medical Conditions ..... 61
   5.3.3.8 Lack of Efficacy or Worsening of Acute Ischemic Stroke ..... 61
   5.3.3.9 Hospitalization or Prolonged Hospitalization ..... 62
   5.3.3.10 Adverse Events Associated with an Overdose ..... 62
   5.3.3.11 Patient-Reported Outcome Data ..... 62
   5.4 Immediate Reporting Requirements from Investigator to Sponsor ..... 62
   Alteplase-Genentech, Inc.
   Protocol ML29093, Version 2 ..... 18
   5.4.1 Emergency Medical Contacts ..... 63
   5.4.2 Reporting Requirements for Serious Adverse Events and Non-Serious Adverse Events of Special Interest ..... 63
   5.4.3 Reporting Requirements for Pregnancies ..... 64
   5.4.3.1 Pregnancies in Female Patients ..... 64
   5.4.3.2 Congenital Anomalies/Birth Defects and Abortions ..... 64
   5.5 Follow-Up of Patients after Adverse Events ..... 64
   5.5.1 Investigator Follow-Up ..... 64
   5.5.2 Sponsor Follow-Up ..... 65
   5.6 Post-Study Adverse Events ..... 65
   5.7 Expedited Reporting to Health Authorities, Investigators, Institutional Review Boards, and Ethics Committees ..... 65
6. STATISTICAL METHODS ..... 66
   6.1 Determination of Sample Size ..... 66
   6.2 Primary Analysis ..... 66
   6.3 Safety Analysis ..... 67
   6.4 Exploratory Analyses ..... 67
   6.5 Interim Analysis ..... 67
   6.6 Missing Data Handling ..... 68
7. DATA COLLECTION AND MANAGEMENT ..... 68
   7.1 Data Quality Assurance ..... 68
   7.2 Electronic Case Report Forms ..... 68
   7.3 Source Data Documentation ..... 69
   7.4 Use of Computerized Systems ..... 69
   7.5 Retention of Records ..... 70
8. ETHICAL CONSIDERATIONS ..... 70
   8.1 Compliance with Laws and Regulations ..... 70
   8.2 Informed Consent ..... 70
   8.3 Institutional Review Board or Ethics Committee ..... 71
   8.4 Confidentiality ..... 71
   8.5 Financial Disclosure ..... 72
   Alteplase-Genentech, Inc.
   Protocol ML29093, Version 2 ..... 19
9. STUDY DOCUMENTATION, MONITORING, AND ADMINISTRATION ..... 72
   9.1 Study Documentation ..... 72
   9.2 Protocol Violations ..... 72
   9.3 Site Inspections ..... 72
   9.4 Administrative Structure ..... 73
   9.5 Protocol Amendments ..... 74
10. REFERENCES ..... 75
    LIST OF TABLES
    Table 1 Comparison of PRISMS and NINDS Studies ..... 32
    Table 2 NIHSS Exclusion Criteria of Recently Completed and Ongoing Acute Ischemic Stroke Trials ..... 37
    Table 3 Intracerebral Hemorrhage Definitions ..... 39
    Table 4 Adverse Event Severity Grading Scale ..... 57
    Table 5 Causal Attribution Guidance ..... 58
    LIST OF FIGURES
    Figure 1 Abbreviated Study Schema ..... 34
    LIST OF APPENDICES
    Appendix 1 Schedule of Assessments ..... 78
    Appendix 2 Alteplase Administration ..... 81
    Appendix 3 Reconstitution of Vials ..... 82
    Appendix 4 European Quality of Life-5D (EQ-5D) Questionnaire ..... 83
    Appendix 5 Stroke Index Scale (SIS-16) ..... 85
    Appendix 6 Center for Epidemiologic Studies, Depression (CES-D) Scale, NIMH ..... 86
    Appendix 7 National Institutes of Health Stroke Scale (NIHSS) ..... 87
    Appendix 8 Modified Rankin Scale (mRS) ..... 91
    Appendix 9 Glasgow Outcome Scale (GOS) ..... 92
    Appendix 10 Barthel Index (BI) ..... 93
    Appendix 11 Cognitive and Behavioral Assessments ..... 95
    Appendix 12 Meter Walk Test ..... 106
    Appendix 13 Preferred Terms for Intracranial Hemorrhage ..... 109
    Appendix 14 World Health Organization (WHO) Toxicity Grading Scale for Determining the Severity of Adverse Events ..... 110

PROTOCOL AMENDMENT ACCEPTANCE FORM

PROTOCOL SYNOPSIS

Objectives

Primary Objectives

Secondary Objectives

• To further evaluate efficacy of IV alteplase to improve mild stroke outcomes at Day 90 via:
• Ordinal mRS
• Global favorable recovery (Global Outcome Measure derived from mRS 0-1, NIHSS 0-1, Barthel Index [BI] , and Glasgow Outcome Scale[GOS] =1)
• To evaluate safety as measured by:
• Symptomatic intracranial hemorrhage (sICH) within 36 hours - primary safety assessment
• Any intracranial hemorrhage (ICH) within 36 hours
• Mortality within 90 days
• Stroke-related and neurological deaths within 90 days
• Incidence, severity, and spectrum of all adverse events (AEs) and serious adverse events (SAEs)

Exploratory Objectives

• NIHSS
• BI
• GOS
• Stroke recurrence (based on AE monitoring) within 90 days
• Cognition and behavior (modified 30 -minute battery: Controlled Oral Word Association test; Hopkins Verbal Learning Test-Revised [HVLT-R] trials 1, 2, and 3; digit symbol coding from the Wechsler Adult Intelligence Scale III [WAIS III]; Forward and Backward Digit Span test; Benton Judgment of Line Orientation, form V; HVLT-R trial 4 and recognition; semantic fluency [Animal Naming test]; and Boston Naming Test [BNT; 15-item short form]) at Day 90
• Ambulatory performance (as measured by walking speed) at Day 90
• Center for Epidemiologic Studies-Depression (CES-D)
• Quality of life (European Quality of Life [EQ-5D] questionnaire) at Day 90
• Stroke Impact Scale-16 (SIS-16) at Day 90

Study Design

Description of Study

1. One dose of alteplase IV (not to exceed 90 mg ) and one dose of oral aspirin placebo, OR
2. One dose of IV alteplase placebo and one dose of oral aspirin 325 mg .

Number of Patients

Target Population

Inclusion Criteria

• Age years (no upper age limit)
• Mild ischemic stroke defined as the most recent pre-treatment NIHSS score of and determined to be not clearly disabling by the investigator. This includes patients with persistently mild deficits as well as those who improve to a pre-treatment NIHSS score (also known as RISS).
• Study treatment can be initiated within 3 hours of last known well time without stroke symptoms (i.e., last seen normal).
• Signed informed consent prior to initiation of any study-specific procedure or treatment. The patient or the patient's legally authorized representative must be able to provide written informed consent and understand the potential risks and benefits from study enrollment and treatment.

Exclusion Criteria

• Computed tomography (CT) or magnetic resonance imaging (MRI) findings consisting of one of the following:
• CT with clear large hypodensity that is greater than one-third middle cerebral artery (MCA) territory (or greater than 100 cc if not in MCA territory),

Alteplase-Genentech, Inc.

• MRI with clear large hyperintensity on concurrent diffusion-weighted (DW) and fluid-attenuated inversion recovery (FLAIR) that is greater than one-third MCA territory (or greater than 100 cc if not in MCA territory),
• Imaging lesion consistent with acute hemorrhage of any degree, OR
• Evidence of intraparenchymal tumor
• Disability prior to the presenting stroke (historical mRS score )
• Standard contraindications to IV alteplase for patients treated within 3 hours of symptom onset, including:
• Head trauma or previous stroke within the previous 3 months
• Myocardial infarction within the previous 3 months
• Gastrointestinal or urinary tract hemorrhage within the previous 21 days
• Major surgery within the previous 14 days
• Arterial puncture at a non-compressible site within the previous 7 days
• Any history of ICH with the exception of chronic microbleeds on MRI
• Elevated blood pressure (systolic or diastolic ), or the use of aggressive measures (use of more than two intravenous agents to lower blood pressure) to achieve blood pressure within acceptable parameters
• Treatment with unfractionated heparin within the last 48 hours and activated partial thromboplastin time outside of the normal range as specified by the center's local laboratory
• Blood glucose
• International normalized ratio (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Platelet count of (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (including novel oral anticoagulants [e.g., dabigatran, rivaroxaban, apixaban, edoxaban]) within the last 48 hours
• Treatment with a low-molecular-weight heparin (e.g., dalteparin, enoxaparin) within the last 48 hours
• Allergic reactions to study drug or aspirin
• Females of childbearing age who are known to be pregnant and/or lactating, or who have a positive pregnancy test on admission
• Inability to swallow, which would prevent oral intake of aspirin or aspirin placebo tablet
• Other serious, advanced, or terminal illness that would confound the clinical outcome at 90 days
• Current or recent (within 3 months) participation in another investigational drug treatment protocol
• Anticipated inability to obtain 3 -month follow-up assessments
• Previous enrollment in PRISMS
• Any other condition that the investigator feels would pose a significant hazard to the patient if treatment with alteplase is initiated

Length of Study

End of Study

Efficacy Outcome Measures

• A favorable functional outcome, defined by an mRS score of 0 or 1 at Day 90 post-randomization
• All mRS assessments will be made by investigators blinded to treatment assignment who are trained and certified in mRS administration.
  The secondary efficacy outcomes at Day 90 include:
• Ordinal mRS
• Global favorable recovery (Global Outcome Measure derived from mRS 0-1, NIHSS 0-1, , and )

Safety Outcome Measures

• Incidence of sICH within 36 hours (primary safety assessment)
  sICH is defined as any neurological decline attributed to new ICH seen on imaging by the investigator. New ICH seen on imaging will be later confirmed on independent reading by blinded central study radiologists.
• Any ICH within 36 hours
• Overall mortality within 90 days
• Stroke-related and neurological deaths within 90 days
• Incidence, severity, and spectrum of all AEs and SAEs

Investigational Medicinal Products

Test Product

Comparator

Non-Investigational Medicinal Products

Comparator

Comparator

Statistical Methods

Primary Analysis

Determination of Sample Size

Interim Analysis

1. BACKGROUND

1.1 BACKGROUND ON ACUTE ISCHEMIC STROKE

1.2 BACKGROUND ON ALTEPLASE

1.2.1 Fibrinolysis and Tissue Plasminogen Activator

1.3 STUDY RATIONALE AND BENEFIT-RISK ASSESSMENT

Alteplase-Genentech, Inc.

2. OBJECTIVES

2.1 PRIMARY OBJECTIVE

2.2 SECONDARY OBJECTIVES

• To further evaluate efficacy of IV alteplase to improve mild stroke outcomes at Day 90 via:
• Ordinal mRS
• Global favorable recovery (Global Outcome Measure derived from mRS 0-1, NIHSS 0-1, Barthel Index [BI] , and Glasgow Outcome Scale [GOS] =1)
• To evaluate safety as measured by:
• sICH within 36 hours (primary safety assessment)
• Any ICH within 36 hours
• Mortality within 90 days
• Stroke-related and neurological deaths within 90 days
• Incidence, severity, and spectrum of all AEs and serious adverse events (SAEs)

2.3 EXPLORATORY OBJECTIVES

• NIHSS
• BI
• GOS
• Stroke recurrence (based on AE monitoring) within 90 days
• Cognition and behavior (modified 30 -minute battery: Controlled Oral Word Association test; Hopkins Verbal Learning Test-Revised [HVLT-R] trials 1, 2, and 3; digit symbol coding from the Wechsler Adult Intelligence Scale III [WAIS III]; Forward and Backward Digit Span test; Benton Judgment of Line Orientation test, form V; HVLT-R trial 4 and recognition; semantic fluency [Animal Naming test]; Boston Naming Test [BNT; 15-item short form]) at Day 90
• Ambulatory performance (as measured by walking speed) at Day 90
• Center for Epidemiologic Studies-Depression (CES-D)
• Quality of life (European Quality of Life [EQ-5D] questionnaire) at Day 90
• Stroke Impact Scale-16 (SIS-16) at Day 90

3. STUDY DESIGN

3.1 DESCRIPTION OF STUDY

1. One dose of alteplase IV (not to exceed 90 mg ) and one dose of oral aspirin placebo, OR
2. One dose of IV alteplase placebo and one dose of oral aspirin 325 mg (Figure 1).

3.2 LENGTH OF STUDY

3.3 END OF STUDY

3.3.1 Number of Patients

3.4 RATIONALE FOR STUDY DESIGN

• Consistent with the currently approved indication in the alteplase USPI: Treatment with alteplase in PRISMS will occur in otherwise eligible AIS patients within 3 hours from the last known well time.
• Conduct of a large, multicenter study: The Sponsor plans to enroll 948 patients across approximately 75 sites in North America. (For comparison, the two NINDS trials enrolled a total of 624 patients.)
• Multiple endpoints involving different events: In addition to the primary efficacy endpoint of mRS at Day 90, which measures disability, secondary endpoints at Day 90 will include an ordinal assessment and global favorable recovery, as calculated using the Global Outcome Measure derived from the mRS, NIHSS, BI, and GOS.

3.4.1 Rationale for Alteplase Dosage

3.4.2 Rationale for Patient Population

1. An NIHSS score is commonly used as an exclusion criterion for many current AIS studies, suggesting that these patients are underrepresented in current stroke research and are treated differently by the stroke community, as shown in Table 2.
2. The largest retrospective analysis of mild stroke from the Get With the Guidelines registry included 29,200 stroke patients who did not receive alteplase due to mild or improving symptoms. This analysis found that of patients with mild or rapidly improving stroke who did not receive alteplase (and had a recorded NIHSS score) had an initial NIHSS score (Smith et al. 2011).

3.4.3 Rationale for Control Group

3.5 OUTCOME MEASURES

3.5.1 Efficacy Outcome Measures

• A favorable functional outcome, defined by an mRS score of 0 or 1 at Day 90 post-randomization
• All mRS assessments will be made by investigators blinded to treatment assignment who are trained and certified in mRS administration.

• Ordinal mRS
• Global favorable recovery (Global Outcome Measure derived from mRS 0-1, NIHSS 0-1, BI , and GOS =1)

Alteplase-Genentech, Inc.

3.5.2 Safety Outcome Measures

• Incidence of sICH within 36 hours (primary safety assessment)
  sICH is defined as any neurological decline attributed to new ICH seen on imaging by the investigator. New ICH seen on imaging will be later confirmed on independent reading by blinded central study radiologists.
• Any ICH within 36 hours
• Overall mortality within 90 days
• Stroke-related and neurological deaths within 90 days
• Incidence, severity, and spectrum of all AEs and SAEs

Symptomatic Intracranial Hemorrhage

3.5.3 Exploratory Outcome Measures

• NIHSS at Day 90
• Instrumental activities of daily living, as measured by the BI at Day 90
• GOS at Day 90
• Stroke recurrence (based on AE monitoring) within 90 days
• Cognition and behavior (modified 30 -minute battery: Controlled Oral Word Association test; Hopkins Verbal Learning Test-Revised [HVLT-R] trials 1, 2, and 3; digit symbol coding from the Wechsler Adult Intelligence Scale III [WAIS III]; Forward and Backward Digit Span test; Benton Judgment of Line Orientation test, form V; HVLT-R trial 4 and recognition; semantic fluency [Animal Naming test]; Boston Naming Test [BNT 15-item short form]) at Day 90
• Ambulatory performance (as measured by walking speed) at Day 90
• Depression (CES-D score) at Day 90
• Quality of life (EQ-5D questionnaire) at Day 90
• SIS-16 at Day 90

4. MATERIALS AND METHODS

4.1 PATIENTS

4.1.1 Inclusion Criteria

• Age years (no upper age limit)
• Mild ischemic stroke defined as the most recent pre-treatment NIHSS score of and determined to be not clearly disabling by the investigator. This includes patients with persistently mild deficits as well as those who improve to a pre-treatment NIHSS score (also known as RISS).
• Study treatment can be initiated within 3 hours of last known well time without stroke symptoms (i.e., last seen normal).
• Signed informed consent prior to initiation of any study-specific procedure or treatment. The patient or the patient's legally authorized representative must be able to provide written informed consent and understand the potential risks and benefits from study enrollment and treatment.

4.1.2 Exclusion Criteria

• CT or MRI findings consisting of one of the following:
• CT with clear large hypodensity that is greater than one-third middle cerebral artery (MCA) territory (or greater than 100 cc if not in MCA territory),
• MRI with clear large hyperintensity on concurrent diffusion-weighted (DW) and fluid-attenuated inversion recovery (FLAIR) that is greater than one-third MCA territory (or greater than 100 cc if not in MCA territory),
• Imaging lesion consistent with acute hemorrhage of any degree, OR
• Evidence of intraparenchymal tumor
• Disability prior to the presenting stroke (historical score )
• Standard contraindications to IV alteplase for patients treated within 3 hours of symptom onset, including:
• Head trauma or previous stroke within the previous 3 months
• Myocardial infarction within the previous 3 months
• Gastrointestinal or urinary tract hemorrhage within the previous 21 days
• Major surgery within the previous 14 days
• Arterial puncture at a non-compressible site within the previous 7 days
• Any history of ICH with the exception of chronic microbleeds on MRI
• Elevated blood pressure (systolic or diastolic ), or the use of aggressive measures (use of more than two intravenous agents to lower blood pressure) to achieve blood pressure within acceptable parameters
• Treatment with unfractionated heparin within the last 48 hours and activated partial thromboplastin time (aPTT) outside of the normal range as specified by the center's local laboratory
• Blood glucose
• International normalized ratio (INR) (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Platelet count of (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (including novel oral anticoagulants [e.g., dabigatran, rivaroxaban, apixaban, edoxaban]) within the last 48 hours
• Treatment with a low-molecular-weight heparin (e.g., dalteparin, enoxaparin) within the last 48 hours
• Allergic reactions to study drug or aspirin
• Females of childbearing age who are known to be pregnant and/or lactating, or who have a positive pregnancy test on admission
• Inability to swallow, which would prevent oral intake of aspirin or aspirin placebo tablet
• Other serious, advanced, or terminal illness that would confound the clinical outcome at 90 days
• Current or recent (within 3 months) participation in another investigational drug treatment protocol
• Anticipated inability to obtain 3 -month follow-up assessments
• Previous enrollment in PRISMS
• Any other condition that the investigator feels would pose a significant hazard to the patient if treatment with alteplase is initiated

4.2 METHOD OF TREATMENT ASSIGNMENT AND BLINDING

Step Forward Randomization

1. IWRS will assign a patient ID to the currently treated patient, which will be correlated to the drug kit ID previously labeled as "Use Next," via the randomization visit record.
2. IWRS will assign a new pair of drug kit IDs for the next patient that becomes eligible at that site to be labeled as "Use Next."

Alteplase-Genentech, Inc.

Study Unblinding

4.3 STUDY TREATMENT

4.3.1 Formulation, Packaging, and Handling

4.3.1.1 Alteplase

Alteplase-Genentech, Inc.

4.3.1.2 Alteplase Placebo

4.3.1.3 Aspirin

4.3.1.4 Aspirin Placebo

4.3.2 Dosage, Administration, and Compliance

4.3.2.1 Alteplase

4.3.3 Investigational Medicinal Product Accountability

4.3.4 Investigational Medicinal Product

4.3.4.1 Alteplase and Placebo

Test Product

Comparator

4.3.4.2 Non-investigational Medicinal Products

Comparator

Comparator

4.3.5 Post-Trial Access to Alteplase

4.4 CONCOMITANT THERAPY

4.4.1 Permitted Therapy

4.4.2 Prohibited Therapy

• Treatment with unfractionated heparin within the last 48 hours and aPTT outside of the normal range as specified by the center's local laboratory
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (including novel oral anticoagulants [e.g., dabigatran, rivaroxaban, apixaban, edoxaban]) within the last 48 hours
• Treatment with a low-molecular-weight heparin (e.g., dalteparin, enoxaparin) within the last 48 hours
• Treatment with warfarin and INR (Note: INR does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)

4.5 STUDY ASSESSMENTS

4.5.1 Description of Study Assessments

4.5.1.1 Informed Consent Forms and Screening Log

4.5.1.2 Medical History and Demographic Data

4.5.1.3 Neurological Examinations

4.5.1.4 Vital Signs

4.5.1.5 Laboratory Assessments

• Complete blood count without differential
• Serum glucose
• Coagulation (INR, aPTT)
• Pregnancy test (serum or urine) for women of childbearing potential including those who have had a tubal ligation

• Complete blood count without differential
• Serum glucose
• Coagulation values (INR, aPTT)
• Pregnancy test for women of childbearing potential including those who have had a tubal ligation

4.5.1.6 Other Disease-Specific Assessments

4.5.2 Patient-Reported Outcomes

4.6 TIMING OF STUDY ASSESSMENTS

4.6.1 Screening/Baseline (Visit 1)

• Medical history
• Demographics
• Neurological examination
• Vital signs
• Complete blood count without differential
• Coagulation status
• Pregnancy test (serum or urine)
• Serum blood glucose
• Non-contrast CT scan or MRI, including DW MRI, either SW or GRE, and FLAIR images
• NIHSS score (Note: This must be performed by an NIHSS-certified practitioner; see Appendix 7)
• Concomitant medications

4.6.2 Visit 2 (22 to Hours after Treatment Initiation)

4.6.3 Visit 3 (Day 5 or Discharge from Hospital, if Sooner than Day 5)

4.6.4 Visit 4 (Day Days)

4.6.5 Visit 5 (Day Days]/Study Completion)

• NIHSS score (Appendix 7)
• Patient survival
• mRS (Appendix 8 )
• GOS (Appendix 9)
• BI (Appendix 10)
• EQ-5D (Appendix 4)
• SIS-16 (Appendix 5)
• CES-D (Appendix 6)
• Cognitive assessments (Appendix 11)
• Controlled Oral Word Association test
• HVLT-R trials 1, 2, and 3
• Digit symbol coding from the WAIS III
• Forward and Backward Digit Span test
• Benton Judgment of Line Orientation test, form V
• HVLT-R trial 4 and recognition
• Animal Naming test

• BNT 15-item short form

• Walking speed (Appendix 12)
• Concomitant medications
• SAEs and certain AEs (See Section 5.3.1)

4.6.6 Early Discontinuation

4.7 PATIENT, TREATMENT, STUDY, AND SITE DISCONTINUATION

4.7.1 Patient Discontinuation

• Patient withdrawal of consent at any time
• Any medical condition that the investigator or Sponsor determines may jeopardize the patient's safety if he or she continues in the study
• Investigator or Sponsor determines it is in the best interest of the patient
• Patient non-compliance, specifically defined as unwillingness to participate in a 3-month assessment of neurological status and function

4.7.2 Study Treatment Discontinuation

• Anaphylactoid reaction (including angioedema)
• Serious bleeding (not controllable by local pressure) at puncture site or serious bleeding in a critical location (e.g., intracranial, gastrointestinal, retroperitoneal, pericardial)

4.7.3 Study and Site Discontinuation

• The incidence or severity of AEs in this or other studies indicates a potential health hazard to patients.
• Patient enrollment is unsatisfactory
• A pre-specified boundary at the interim analysis was crossed

• Excessively slow recruitment
• Poor protocol adherence
• Inaccurate or incomplete data recording
• Non-compliance with the International Conference on Harmonisation guideline for Good Clinical Practice
• No study activity (i.e., all patients have completed study assessments and all obligations have been fulfilled)

5. ASSESSMENT OF SAFETY

5.1 SAFETY PLAN

5.1.1 Risk of Bleeding

• The incidence of ICH, especially symptomatic ICH, in patients with AIS is higher in alteplase-treated patients than placebo-treated patients in published studies (for detailed information, see the alteplase USPI).

Management of Bleeding

5.1.2 Risk of Allergic Reactions

Management of Allergic Reaction

5.2 SAFETY PARAMETERS AND DEFINITIONS

5.2.1 Adverse Events

• Any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal product, whether or not considered related to the medicinal product
• Any new disease or exacerbation of an existing disease (a worsening in the character, frequency, or severity of a known condition), except as described in Section 5.3.3.9
• Recurrence of an intermittent medical condition (e.g., headache) not present at baseline
• Any deterioration in a laboratory value or other clinical test (e.g., electrocardiogram, X-ray) that is associated with symptoms or leads to a change in study treatment or concomitant treatment or discontinuation from study drug

5.2.2 Serious Adverse Events (Immediately Reportable to the Sponsor)

• Fatal (i.e., the AE actually causes or leads to death)
• Life-threatening (i.e., the AE , in the view of the investigator, places the patient at immediate risk of death)

• Requires or prolongs inpatient hospitalization (see Section 5.3.3.9)
• Results in persistent or significant disability/incapacity (i.e., the AE results in substantial disruption of the patient's ability to conduct normal life functions)
• Congenital anomaly/birth defect in a neonate/infant born to a mother exposed to study drug
• Significant medical event in the investigator's judgment (e.g., may jeopardize the patient or may require medical/surgical intervention to prevent one of the outcomes listed above)

5.2.3 Non-Serious Adverse Events of Special Interest (Immediately Reportable to the Sponsor)

• sICH events, if not already reported as an SAE (for a list of preferred terms for ICH see Appendix 13)
• Stroke recurrence: report if the resulted in a substantial disruption of a person's ability to conduct normal life functions (i.e., the AE resulted in a significant, persistent, or permanent change; impairment; or damage or disruption in the patient's body function/structure, physical activities, and/or quality of life.
• In addition, Suspected Transmission of an Infectious Agent via a Medicinal Product (STIAMP) by the study drug in a Genentech-sponsored trial qualifies as an AESI and requires immediate reporting to the Sponsor.

5.3 METHODS AND TIMING FOR CAPTURING AND ASSESSING SAFETY PARAMETERS

5.3.1 Adverse Event Reporting Period

• All SAEs
• Non-serious ICHs
• Non-serious AESIs
• All AEs that resulted in withdrawal from the study

5.3.2 Assessment of Severity of Adverse Events

5.3.3 Assessment of Causality of Adverse Events

• Temporal relationship of event onset to the initiation of study drug
• Course of the event, considering especially the effects of dose reduction, discontinuation of study drug, or reintroduction of study drug (as applicable)
• Known association of the event with the study drug or with similar treatments
• Known association of the event with the disease under study
• Presence of risk factors in the patient or use of concomitant medications known to increase the occurrence of the event
• Presence of non-treatment-related factors that are known to be associated with the occurrence of the event

Table 5 Causal Attribution Guidance

5.3.3.1 Diagnosis versus Signs and Symptoms

5.3.3.2 Adverse Events Occurring Secondary to Other Events

• If vomiting results in mild dehydration with no additional treatment in a healthy adult, only vomiting should be reported on the eCRF.
• If vomiting results in severe dehydration, both events should be reported separately on the eCRF .
• If a severe gastrointestinal hemorrhage leads to renal failure, both events should be reported separately on the eCRF.
• If dizziness leads to a fall and consequent fracture, all three events should be reported separately on the eCRF.
• If neutropenia is accompanied by an infection, both events should be reported separately on the eCRF.

5.3.3.3 Persistent or Recurrent Adverse Events

5.3.3.4 Abnormal Laboratory Values

• Accompanied by clinical symptoms
• Results in a change in study treatment (e.g., dosage modification, treatment interruption, or treatment discontinuation)
• Results in a medical intervention (e.g., potassium supplementation for hypokalemia) or a change in concomitant therapy
• Clinically significant in the investigator's judgment

5.3.3.5 Abnormal Vital Sign Values

• Accompanied by clinical symptoms
• Results in a change in study treatment (e.g., dosage modification, treatment interruption, or treatment discontinuation)
• Results in a medical intervention or a change in concomitant therapy
• Clinically significant in the investigator's judgment

Alteplase-Genentech, Inc.

5.3.3.6 Deaths

5.3.3.7 Preexisting Medical Conditions

5.3.3.8 Lack of Efficacy or Worsening of Acute Ischemic Stroke

5.3.3.9 Hospitalization or Prolonged Hospitalization

• Hospitalization for respite care
• Hospitalization for a preexisting condition, provided that all of the following criteria are met:
• The hospitalization was planned prior to the study or was scheduled during the study when elective surgery became necessary because of the expected normal progression of the disease.
• The patient has not suffered an AE.

5.3.3.10 Adverse Events Associated with an Overdose

5.3.3.11 Patient-Reported Outcome Data

5.4 IMMEDIATE REPORTING REQUIREMENTS FROM INVESTIGATOR TO SPONSOR

• SAEs
• Non-serious AESIs
• Pregnancies

• New signs or symptoms or a change in the diagnosis
• Significant new diagnostic test results
• Change in causality based on new information
• Change in the event's outcome, including recovery
• Additional narrative information on the clinical course of the event

5.4.1 Emergency Medical Contacts

Medical Monitor Contact Information

5.4.2 Reporting Requirements for Serious Adverse Events and Non-Serious Adverse Events of Special Interest

5.4.3 Reporting Requirements for Pregnancies

5.4.3.1 Pregnancies in Female Patients

5.4.3.2 Congenital Anomalies/Birth Defects and Abortions

5.5 FOLLOW-UP OF PATIENTS AFTER ADVERSE EVENTS

5.5.1 Investigator Follow-Up

5.5.2 Sponsor Follow-Up

5.6 POST-STUDY ADVERSE EVENTS

5.7 EXPEDITED REPORTING TO HEALTH AUTHORITIES, INVESTIGATORS, INSTITUTIONAL REVIEW BOARDS, AND ETHICS COMMITTEES

• Alteplase USPI

6. STATISTICAL METHODS

6.1 DETERMINATION OF SAMPLE SIZE

6.2 PRIMARY ANALYSIS

6.3 SAFETY ANALYSIS

6.4 EXPLORATORY ANALYSES

• Age (<65 vs. )
• Pre-treatment NIHSS score (0-2 vs. 3-5)
• Last known well time to treatment ( vs. hours)
• Stroke subgroup (RISS vs. non-RISS)

6.5 INTERIM ANALYSIS

6.6 MISSING DATA HANDLING

7. DATA COLLECTION AND MANAGEMENT

7.1 DATA QUALITY ASSURANCE

7.2 ELECTRONIC CASE REPORT FORMS

7.3 SOURCE DATA DOCUMENTATION

7.4 USE OF COMPUTERIZED SYSTEMS

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7.5 RETENTION OF RECORDS

8. ETHICAL CONSIDERATIONS

8.1 COMPLIANCE WITH LAWS AND REGULATIONS

8.2 INFORMED CONSENT

8.3 INSTITUTIONAL REVIEW BOARD OR ETHICS COMMITTEE

8.4 CONFIDENTIALITY

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8.5 FINANCIAL DISCLOSURE

9. STUDY DOCUMENTATION, MONITORING, AND ADMINISTRATION

9.1 STUDY DOCUMENTATION

9.2 PROTOCOL VIOLATIONS

9.3 SITE INSPECTIONS

9.4 ADMINISTRATIVE STRUCTURE

• Provide recommendations regarding changes in the study conduct
• Review results of the final analyses for primary and secondary endpoints
• Participate in the drafting and publishing of final study results

• Review all accumulated safety data at interim analysis
• Review efficacy data analysis performed for interim analysis for consideration of potential discontinuation of the trial for futility
• Make recommendation to the Sponsor as to if it is appropriate to discontinue the study after assessing the interim efficacy and safety data in aggregate
• Determine if the study should continue after review of interim analysis results

9.5 PROTOCOL AMENDMENTS

10. REFERENCES

Appendix 1
Schedule of Assessments

Appendix 1 (cont.)
Schedule of Assessments

Appendix 1 (cont.) Schedule of Assessments

Appendix 2
Alteplase Administration

Administration of bolus

Step 1:

Inspect solution

Step 2:

Step 3:

Step 4:

Administration of remainder of dose

Appendix 3
Reconstitution of Vials

Step 1:

Step 2:

Step 3:

Step 4:

Step 5:

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Appendix 4
European Quality of Life-5D (EQ-5D) Questionnaire

Appendix 4 (cont.)
European Quality of Life-5D (EQ-5D) Questionnaire

Appendix 5
Stroke Index Scale (SIS-16)

Appendix 6
Center for Epidemiologic Studies, Depression (CES-D) Scale, NIMH

Appendix 7 National Institutes of Health Stroke Scale (NIHSS)

Appendix 7 (cont.) National Institutes of Health Stroke Scale (NIHSS)

Appendix 7 (cont.) National Institutes of Health Stroke Scale (NIHSS)

Appendix 7 (cont.)
National Institutes of Health Stroke Scale (NIHSS)

Appendix 8 Modified Rankin Scale (mRS)

Appendix 9 Glasgow Outcome Scale (GOS)

References

Appendix 10
Barthel Index (BI)

ActivityScore

0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
\(10=\) independent

BATHING

\(0=\) dependent
\(5=\) independent (or in shower)

GROOMING

\(0=\) needs to help with personal care
\(5=\) independent face/hair/teeth/shaving (implements provided)
DRESSING
\(0=\) dependent
\(5=\) needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)

BOWELS

\(0=\) incontinent (or needs to be given enemas)
\(5=\) occasional accident
10 = continent

BLADDER

0= incontinent, or catheterized and unable to manage alone
\(5=\) occasional accident
10 = continent

TOILET USE

\(0=\) dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)

TRANSFERS (BED TO CHAIR AND BACK)

0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
\(10=\) minor help (verbal or physical)
\(15=\) independent
MOBILITY (ON LEVEL SURFACES)
\(0=\) immobile or \(<50\) yards
\(5=\) wheelchair independent, including comers, \(>50\) yards
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards

STAIRS

0 = unable
\(5=\) needs help (verbal, physical, carrying aid)
10 = independent

TOTAL (0-100):

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Appendix 10 (cont.)
Barthel Index (BI)

The Barthel ADL Index: Guidelines

1. The index should be used as a record of what a patient does, not as a record of what a patient could do.
2. The main aim is to establish degree of independence from any help, physical or verbal, however minor and for whatever reason.
3. The need for supervision renders the patient not independent.
4. A patient's performance should be established using the best available evidence. Asking the patient, fiiends/relatives and nurses are the usual sources, but direct observation and common sense are also important. However direct testing is not needed.
5. Usually the patient's performance over the preceding hours is important, but occasionally longer periods will be relevant.
6. Middle categories imply that the patient supplies over 50 per cent of the effort.
7. Use of aids to be independent is allowed.

Appendix 11 Cognitive and Behavioral Assessments

A. Controlled Oral Word Association Test

Appendix 11 (cont.)
Cognitive and Behavioral Assessments

B . Hopkins Verbal Learning Test-Revised (HVLT-R)

Appendix 11 (cont.) Cognitive and Behavioral Assessments

Delayed Recognition Trial Instructions

Appendix 11 (cont.) Cognitive and Behavioral Assessments

C. Digit Symbol Coding from the WAIS III

Appendix 11 (cont.) Cognitive and Behavioral Assessments

D. Forward and Backward Digit Span Test

FORWARD AND BACKWARD DIGIT SPAN TEST DIGIT SPAN (FORWARD)*

DIGIT SPAN (BACKWARD)*

Appendix 11 (cont.)
Cognitive and Behavioral Assessments

E. Benton Judgment of Line Orientation

Benton Judgment Of Line Orientation - Form V

TEST ITEMS

Appendix 11 (cont.) Cognitive and Behavioral Assessments

F. Animal Naming Test

ANIMAL NAMING

Scoring: Count the total number of animals (NOT including repetitions or non-animal words):

Next step: If the score is less than 14, further testing should be done.

Sager MD, MA; Hermann PhD, BP; LaRue PhD, A; Woodard PhD, JL, Screening for Dementia in Community-based Memory Clinics. Wisconsin Medical Journal 2006.105(7)25-29

Appendix 11 (cont.) Cognitive and Behavioral Assessments

Directions for Scoring Animal Naming Screen

Appendix 11 (cont.)
Cognitive and Behavioral Assessments

G. Boston Naming Test (BNT) 15-Item Short Form

SHORT FORM

Appendix 11 (cont.)

Cognitive and Behavioral Assessments

Appendix 11 (cont.) Cognitive and Behavioral Assessments

1. Number of spontaneously given correct responses
   
2. Number of stimulus cues given
3. Number of correct responses following a stimulus cue
   4. Number of phonemic cues
   5. Number of correct responses following the phonemic cue
   6. Number of multiple choices given
   7. Number of correct choices
   
   Total Number Correct ( )
   Total Score:(Add credit for items preceding the first itempassed. Disregard if you started with item 1.)
   Tally of paraphasia types
4. Phonological (sum of ph and ph/v)
   2. Verbal (sum of and )
   3. Neologistic
   4. Multi-word
   5. Perceptual
   

Appendix 12

10 Meter Walk Test

Physical Assistance Provided During Testing:

Test Administration:

Appendix 12 (cont.) 10 Meter Walk Test

7. Instructions for Recording Time:
   □ START the stopwatch when the subject's first foot crosses the plane of the 2 meter line
   □ STOP the stopwatch when the subject's first foot crosses the plane of the 12 meter line.
   □ Have the subject continue walking until he/she reaches the chair after the 14 meter line.
   □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance
   "Comfortable" Pace Trial 1 line on the 10 Meter Walk Test Source Document.
   □ The subject can rest, if needed, in the chair near the 14 meter line.
8. When the subject is ready, have them repeat the SAME PROCEDURE except they will start from the 14 meter line and end at 0 meter line.
   □ START the stopwatch when the subject's first foot crosses the plane of the 12 meter line
   □ STOP the stopwatch when the subject's first foot crosses the plane of the 2 meter line.
   □ Have the subject continue walking until he/she reaches the chair after the 0 meter line.
   □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance on the "Comfortable" Pace Trial 2 line on the 10 Meter Walk Test Source Document.
   □ The subject can rest, if needed, in the chair near the 0 meter line.
9. Subject Instructions for the last 2 trials:
   "You are going to walk the same distances for two additional trials as quickly and as safely as you can. Do you have any questions?"
10. When the subject is ready, walk the subject to the start line ( 0 meters). Provide the subject with the following instructions:
    "You will walk as quickly and as safely as you can to the chair." (Use an appropriate descriptor for chair/location, but DO NOT refer to the tape on the floor.) The start command is "Ready and Go".
11. When you and the subject are ready, say "Ready and Go". If the subject starts too early, have them start again.

Appendix 12 (cont.) 10 Meter Walk Test

12. Instructions for Recording Time:
    □ START the stopwatch when the subject's first foot crosses the plane of the 2 meter line
    □ STOP the stopwatch when the subject's first foot crosses the plane of the 12 meter line.
    □ Have the subject continue walking until he/she reaches the chair after the 14 meter line.
    □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance on the "As Fast As Possible" Pace Trial 1 line on the 10 Meter Walk Test Source Document.
    □ The subject can rest, if needed, in the chair near the 14 meter line.
13. When the subject is ready, have them repeat the SAME PROCEDURE except they will start from the 14 meter line and end at 0 meter line.
    □ START the stopwatch when the subject's first foot crosses the plane of the 12 meter line
    □ STOP the stopwatch when the subject's first foot crosses the plane of the 2 meter line.
    □ Have the subject continue walking until he/she reaches the chair after the 0 meter line.
    □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance on the "As Fast As Possible" Pace Trial 2 line on the 10 Meter Walk Test Source Document.
    □ The subject can rest, if needed, in the chair near the 0 meter line.
14. Record the assistive device used and the Functional Ambulation Category (FAC) on the 10 Meter Walk Test Source Document.

REFERENCES:

Appendix 13
Preferred Terms for Intracranial Hemorrhage

• Basal ganglia hemorrhage
• Brain stem hematoma
• Brain stem hemorrhage
• Brain stem microhemorrhage
• Cerebellar hematoma
• Cerebellar hemorrhage
• Cerebellar microhemorrhage
• Cerebral arteriovenous malformation hemorrhagic
• Cerebral hematoma
• Cerebral hemorrhage
• Cerebral microhemorrhage
• Epidural hemorrhage
• Extradural hematoma
• Hemorrhage intracranial
• Hemorrhagic cerebral infarction
• Hemorrhagic stroke
• Hemorrhagic transformation stroke
• Intracranial hematoma
• Intraventricular hemorrhage
• Meningorrhagia
• Pituitary hemorrhage
• Putamen hemorrhage
• Subarachnoid hemorrhage
• Subdural hematoma
• Subdural hemorrhage
• Thalamus hemorrhage
• Traumatic intracranial hemorrhage

Appendix 14

World Health Organization (WHO) Toxicity Grading Scale for Determining the Severity of Adverse Events

Appendix 14 (cont.)

World Health Organization (WHO) Toxicity Grading Scale for Determining the Severity of Adverse Events

Appendix 14 (cont.)

World Health Organization (WHO) Toxicity Grading Scale for Determining the Severity of Adverse Events

Appendix 14 (cont.)

World Health Organization (WHO) Toxicity Grading Scale for Determining the Severity of Adverse Events

PROTOCOL

CONFIDENTIAL STATEMENT

PROTOCOL AMENDMENT, VERSION 3: RATIONALE

• The exclusion criterion regarding allergic reactions to study drug and/or aspirin was expanded to include nonsteroidal anti-inflammatory drugs (NSAIDs) as well.

PROTOCOL AMENDMENT, VERSION 3: SUMMARY OF CHANGES

PROTOCOL SYNOPSIS

SECTION 4.1.2: Exclusion Criteria

• Allergic reactions to study drug,-or aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs)

SECTION 4.2: METHOD OF TREATMENT ASSIGNMENT AND BLINDING Study Unblinding

SECTION 4.5.1.1: Informed Consent Forms and Screening Log

SECTION 4.7.2: Study Treatment Discontinuation

SECTION 5.2: SAFETY PARAMETERS AND DEFINITIONS

SECTION 5.3.3.3: Persistent or Recurrent Adverse Events

SECTION 5.3.3.4: Abnormal Laboratory Values

SECTION 5.3.3.5: Abnormal Vital Sign Values

SECTION 5.3.3.10: Adverse Events Associated with an Overdose or Error in Drug Administration

SECTION 5.4: IMMEDIATE REPORTING REQUIREMENTS FROM INVESTIGATOR TO SPONSOR

• SAEs (see Section 5.4.2 for further details)
• Non-serious AESIs (see Section 5.4.2 for further details)
• Pregnancies (see Section 5.4.3 for further details)

SECTION 5.4.2: Reporting Requirements for Serious Adverse Events and Non-Serious Adverse Events of Special Interest

SECTION 5.4.3.1: Pregnancies in Female Patients

SECTION 5.5.1: Investigator Follow-Up

SECTION 5.6: POST-STUDY ADVERSE EVENTS

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SECTION 8.2: INFORMED CONSENT

SECTION 9.5: PUBLICATION OF DATA AND PRTOECTION OF TRADE SECRETS

APPENDIX 1: Schedule of Assessments

TABLE OF CONTENTS

1. BACKGROUND ..... 21
   1.1 Background on Acute Ischemic Stroke ..... 21
   1.2 Background on Alteplase ..... 21
   1.2.1 Fibrinolysis and Tissue Plasminogen Activator ..... 21
   1.3 Study Rationale and Benefit-Risk Assessment ..... 22
2. OBJECTIVES ..... 24
   2.1 Primary Objective ..... 24
   2.2 Secondary Objectives ..... 24
   2.3 Exploratory Objectives ..... 25
3. STUDY DESIGN ..... 25
   3.1 Description of Study ..... 25
   3.2 Length of Study ..... 27
   3.3 End of Study ..... 27
   3.3.1 Number of Patients ..... 27
   3.4 Rationale for Study Design ..... 27
   3.4.1 Rationale for Alteplase Dosage ..... 27
   3.4.2 Rationale for Patient Population ..... 28
   3.4.3 Rationale for Control Group ..... 30
   3.5 Outcome Measures ..... 30
   3.5.1 Efficacy Outcome Measures ..... 30
   3.5.2 Safety Outcome Measures ..... 31
   3.5.3 Exploratory Outcome Measures ..... 32
4. MATERIALS AND METHODS ..... 32
   4.1 Patients ..... 32
   4.1.1 Inclusion Criteria ..... 32
   4.1.2 Exclusion Criteria ..... 33
   4.2 Method of Treatment Assignment and Blinding ..... 34
   4.3 Study Treatment ..... 35
   4.3.1 Formulation, Packaging, and Handling ..... 35
   4.3.1.1 Alteplase ..... 35
   4.3.1.2 Alteplase Placebo ..... 36
   4.3.1.3 Aspirin ..... 36
   4.3.1.4 Aspirin Placebo ..... 36
   4.3.2 Dosage, Administration, and Compliance ..... 36
   4.3.2.1 Alteplase ..... 36
   4.3.3 Investigational Medicinal Product Accountability ..... 37
   4.3.4 Investigational Medicinal Product ..... 38
   4.3.4.1 Alteplase and Placebo ..... 38
   4.3.4.2 Non-investigational Medicinal Products ..... 38
   4.3.5 Post-Trial Access to Alteplase ..... 38
   4.4 Concomitant Therapy ..... 38
   4.4.1 Permitted Therapy ..... 38
   4.4.2 Prohibited Therapy ..... 38
   4.5 Study Assessments ..... 39
   4.5.1 Description of Study Assessments ..... 39
   4.5.1.1 Informed Consent Forms and Screening Log ..... 39
   4.5.1.2 Medical History and Demographic Data ..... 39
   4.5.1.3 Neurological Examinations ..... 39
   4.5.1.4 Vital Signs ..... 40
   4.5.1.5 Laboratory Assessments ..... 40
   4.5.1.6 Other Disease-Specific Assessments ..... 40
   4.5.2 Patient-Reported Outcomes ..... 41
   4.6 Timing of Study Assessments ..... 42
   4.6.1 Screening/Baseline (Visit 1) ..... 42
   4.6.2 Visit 2 (22 to 36 Hours after Treatment Initiation) ..... 42
   4.6.3 Visit 3 (Day 5 or Discharge from Hospital, if Sooner than Day 5) ..... 43
   4.6.4 Visit 4 (Day 30 [30 ± 7 Days]) ..... 43
   4.6.5 Visit 5 (Day 90 [ ± 14 Days]/Study Completion) ..... 43
   4.6.6 Early Discontinuation ..... 44
   4.7 Patient, Treatment, Study, and Site Discontinuation ..... 44
   4.7.1 Patient Discontinuation ..... 44
   4.7.2 Study Treatment Discontinuation ..... 44
   4.7.3 Study and Site Discontinuation ..... 45
5. ASSESSMENT OF SAFETY ..... 45
   5.1 Safety Plan ..... 45
   5.1.1 Risk of Bleeding ..... 46
   5.1.2 Risk of Allergic Reactions ..... 46
   5.2 Safety Parameters and Definitions ..... 46
   5.2.1 Adverse Events ..... 47
   5.2.2 Serious Adverse Events (Immediately Reportable to the Sponsor) ..... 47
   5.2.3 Non-Serious Adverse Events of Special Interest (Immediately Reportable to the Sponsor) ..... 48
   5.3 Methods and Timing for Capturing and Assessing Safety Parameters ..... 48
   5.3.1 Adverse Event Reporting Period ..... 48
   5.3.2 Assessment of Severity of Adverse Events ..... 49
   5.3.3 Assessment of Causality of Adverse Events ..... 50
   5.3.3.1 Diagnosis versus Signs and Symptoms ..... 50
   5.3.3.2 Adverse Events Occurring Secondary to Other Events ..... 51
   5.3.3.3 Persistent or Recurrent Adverse Events ..... 51
   5.3.3.4 Abnormal Laboratory Values ..... 51
   5.3.3.5 Abnormal Vital Sign Values ..... 52
   5.3.3.6 Deaths ..... 53
   5.3.3.7 Preexisting Medical Conditions ..... 53
   5.3.3.8 Lack of Efficacy or Worsening of Acute Ischemic Stroke ..... 53
   5.3.3.9 Hospitalization or Prolonged Hospitalization ..... 54
   5.3.3.10 Adverse Events Associated with an Overdose or Error in Drug Administration ..... 54
   5.3.3.11 Patient-Reported Outcome Data ..... 54
   5.4 Immediate Reporting Requirements from Investigator to Sponsor ..... 54
   5.4.1 Emergency Medical Contacts ..... 55
   5.4.2 Reporting Requirements for Serious Adverse Events and Non-Serious Adverse Events of Special Interest ..... 55
   5.4.3 Reporting Requirements for Pregnancies ..... 56
   5.4.3.1 Pregnancies in Female Patients ..... 56
   5.4.3.2 Congenital Anomalies/Birth Defects and Abortions ..... 56
   5.5 Follow-Up of Patients after Adverse Events ..... 56
   5.5.1 Investigator Follow-Up ..... 56
   5.5.2 Sponsor Follow-Up ..... 57
   5.6 Post-Study Adverse Events ..... 57
   5.7 Expedited Reporting to Health Authorities, Investigators, Institutional Review Boards, and Ethics Committees ..... 57
6. STATISTICAL METHODS ..... 58
   6.1 Determination of Sample Size ..... 58
   6.2 Primary Analysis ..... 58
   6.3 Safety Analysis ..... 59
   6.4 Exploratory Analyses ..... 59
   6.5 Interim Analysis ..... 59
   6.6 Missing Data Handling ..... 60
7. DATA COLLECTION AND MANAGEMENT ..... 60
   7.1 Data Quality Assurance ..... 60
   7.2 Electronic Case Report Forms ..... 60
   7.3 Source Data Documentation ..... 61
   7.4 Use of Computerized Systems ..... 61
   7.5 Retention of Records ..... 62
8. ETHICAL CONSIDERATIONS ..... 62
   8.1 Compliance with Laws and Regulations ..... 62
   8.2 Informed Consent ..... 62
   8.3 Institutional Review Board or Ethics Committee ..... 63
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   10/Protocol ML29093, Version 3
   8.4 Confidentiality ..... 63
   8.5 Financial Disclosure ..... 64
9. STUDY DOCUMENTATION, MONITORING, AND ADMINISTRATION ..... 64
   9.1 Study Documentation ..... 64
   9.2 Protocol Violations ..... 64
   9.3 Site Inspections ..... 64
   9.4 Administrative Structure ..... 65
   9.5 Publication of Data and Protection of Trade Secrets ..... 65
   9.6 Protocol Amendments ..... 66
10. REFERENCES ..... 67
    LIST OF TABLES
    Table 1 Comparison of PRISMS and NINDS Studies ..... 24
    Table 2 NIHSS Exclusion Criteria of Recently Completed and Ongoing Acute Ischemic Stroke Trials ..... 29
    Table 3 Intracerebral Hemorrhage Definitions ..... 31
    Table 4 Adverse Event Severity Grading Scale ..... 49
    Table 5 Causal Attribution Guidance ..... 50
    LIST OF FIGURES
    Figure 1 Abbreviated Study Schema ..... 26
    LIST OF APPENDICES
    Appendix 1 Schedule of Assessments ..... 70
    Appendix 2 Alteplase Administration ..... 73
    Appendix 3 Reconstitution of Vials ..... 74
    Appendix 4 European Quality of Life-5D (EQ-5D) Questionnaire ..... 75
    Appendix 5 Stroke Index Scale (SIS-16) ..... 77
    Appendix 6 Center for Epidemiologic Studies, Depression (CES-D) Scale, NIMH ..... 78
    Appendix 7 National Institutes of Health Stroke Scale (NIHSS) ..... 79
    Appendix 8 Modified Rankin Scale (mRS) ..... 83
    Appendix 9 Glasgow Outcome Scale (GOS) ..... 84
    Appendix 10 Barthel Index (BI) ..... 85
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    11/Protocol ML29093, Version 3
    Appendix 11 Cognitive and Behavioral Assessments ..... 87
    Appendix 1210 Meter Walk Test ..... 98
    Appendix 13 Preferred Terms for Intracranial Hemorrhage ..... 101
    Appendix 14 World Health Organization (WHO) Toxicity Grading Scale for Determining the Severity of Adverse Events ..... 102

PROTOCOL AMENDMENT ACCEPTANCE FORM

PROTOCOL SYNOPSIS

Primary Objectives

Secondary Objectives

• To further evaluate efficacy of IV alteplase to improve mild stroke outcomes at Day 90 via:
• Ordinal mRS
• Global favorable recovery (Global Outcome Measure derived from mRS 0-1, NIHSS 0-1, Barthel Index [BI] , and Glasgow Outcome Scale [GOS]=1)
• To evaluate safety as measured by:
• Symptomatic intracranial hemorrhage (sICH) within 36 hours - primary safety assessment
• Any intracranial hemorrhage (ICH) within 36 hours
• Mortality within 90 days
• Stroke-related and neurological deaths within 90 days
• Incidence, severity, and spectrum of all adverse events (AEs) and serious adverse events (SAEs)

Exploratory Objectives

• NIHSS
• BI
• GOS
• Stroke recurrence (based on AE monitoring) within 90 days
• Cognition and behavior (modified 30 -minute battery: Controlled Oral Word Association test; Hopkins Verbal Learning Test-Revised [HVLT-R] trials 1, 2, and 3; digit symbol coding from the Wechsler Adult Intelligence Scale III [WAIS III]; Forward and Backward Digit Span test; Benton Judgment of Line Orientation, form V; HVLT-R trial 4 and recognition; semantic fluency [Animal Naming test]; and Boston Naming Test [BNT; 15-item short form]) at Day 90
• Ambulatory performance (as measured by walking speed) at Day 90
• Center for Epidemiologic Studies-Depression (CES-D)
• Quality of life (European Quality of Life [EQ-5D] questionnaire) at Day 90
• Stroke Impact Scale-16 (SIS-16) at Day 90

Study Design

Description of Study

1. One dose of alteplase IV (not to exceed 90 mg ) and one dose of oral aspirin placebo, OR
2. One dose of IV alteplase placebo and one dose of oral aspirin 325 mg .

Number of Patients

Target Population

Inclusion Criteria

• Age years (no upper age limit)
• Mild ischemic stroke defined as the most recent pre-treatment NIHSS score of and determined to be not clearly disabling by the investigator. This includes patients with persistently mild deficits as well as those who improve to a pre-treatment NIHSS score (also known as RISS).
• Study treatment can be initiated within 3 hours of last known well time without stroke symptoms (i.e., last seen normal).
• Signed informed consent prior to initiation of any study-specific procedure or treatment. The patient or the patient's legally authorized representative must be able to provide written informed consent and understand the potential risks and benefits from study enrollment and treatment.

Exclusion Criteria

• Computed tomography (CT) or magnetic resonance imaging (MRI) findings consisting of one of the following:
• CT with clear large hypodensity that is greater than one-third middle cerebral artery (MCA) territory (or greater than 100 cc if not in MCA territory),

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• MRI with clear large hyperintensity on concurrent diffusion-weighted (DW) and fluidattenuated inversion recovery (FLAIR) that is greater than one-third MCA territory (or greater than 100 cc if not in MCA territory),
• Imaging lesion consistent with acute hemorrhage of any degree, OR
• Evidence of intraparenchymal tumor
• Disability prior to the presenting stroke (historical mRS score )
• Standard contraindications to IV alteplase for patients treated within 3 hours of symptom onset, including:
• Head trauma or previous stroke within the previous 3 months
• Myocardial infarction within the previous 3 months
• Gastrointestinal or urinary tract hemorrhage within the previous 21 days
• Major surgery within the previous 14 days
• Arterial puncture at a non-compressible site within the previous 7 days
• Any history of ICH with the exception of chronic microbleeds on MRI
• Elevated blood pressure (systolic or diastolic ), or the use of aggressive measures (use of more than two intravenous agents to lower blood pressure) to achieve blood pressure within acceptable parameters
• Treatment with unfractionated heparin within the last 48 hours and activated partial thromboplastin time outside of the normal range as specified by the center's local laboratory
• Blood glucose
• International normalized ratio (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Platelet count of (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (including novel oral anticoagulants [e.g., dabigatran, rivaroxaban, apixaban, edoxaban]) within the last 48 hours
• Treatment with a low-molecular-weight heparin (e.g., dalteparin, enoxaparin) within the last 48 hours
• Allergic reactions to study drug, aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs)
• Females of childbearing age who are known to be pregnant and/or lactating, or who have a positive pregnancy test on admission
• Inability to swallow, which would prevent oral intake of aspirin or aspirin placebo tablet
• Other serious, advanced, or terminal illness that would confound the clinical outcome at 90 days
• Current or recent (within 3 months) participation in another investigational drug treatment protocol
• Anticipated inability to obtain 3 -month follow-up assessments
• Previous enrollment in PRISMS
• Any other condition that the investigator feels would pose a significant hazard to the patient if treatment with alteplase is initiated

Length of Study

End of Study

Efficacy Outcome Measures

• A favorable functional outcome, defined by an mRS score of 0 or 1 at Day 90 post-randomization
• All mRS assessments will be made by investigators blinded to treatment assignment who are trained and certified in mRS administration.
  The secondary efficacy outcomes at Day 90 include:
• Ordinal mRS
• Global favorable recovery (Global Outcome Measure derived from mRS 0-1, NIHSS 0-1, , and )

Safety Outcome Measures

• Incidence of sICH within 36 hours (primary safety assessment)
  sICH is defined as any neurological decline attributed to new ICH seen on imaging by the investigator. New ICH seen on imaging will be later confirmed on independent reading by blinded central study radiologists.
• Any ICH within 36 hours
• Overall mortality within 90 days
• Stroke-related and neurological deaths within 90 days
• Incidence, severity, and spectrum of all AEs and SAEs

Investigational Medicinal Products

Test Product (Investigational Drug)

Comparator

Non-Investigational Medicinal Products

Comparator

Comparator

Statistical Methods

Primary Analysis

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Determination of Sample Size

Interim Analysis

1. BACKGROUND

1.1 BACKGROUND ON ACUTE ISCHEMIC STROKE

1.2 BACKGROUND ON ALTEPLASE

1.2.1 Fibrinolysis and Tissue Plasminogen Activator

1.3 STUDY RATIONALE AND BENEFIT-RISK ASSESSMENT

2. OBJECTIVES

2.1 PRIMARY OBJECTIVE

2.2 SECONDARY OBJECTIVES

• To further evaluate efficacy of IV alteplase to improve mild stroke outcomes at Day 90 via:
• Ordinal mRS
• Global favorable recovery (Global Outcome Measure derived from mRS 0-1, NIHSS 0-1, Barthel Index [BI] , and Glasgow Outcome Scale [GOS]=1)
• To evaluate safety as measured by:

• sICH within 36 hours (primary safety assessment)
• Any ICH within 36 hours
• Mortality within 90 days
• Stroke-related and neurological deaths within 90 days
• Incidence, severity, and spectrum of all AEs and serious adverse events (SAEs)

2.3 EXPLORATORY OBJECTIVES

• NIHSS
• BI
• GOS
• Stroke recurrence (based on AE monitoring) within 90 days
• Cognition and behavior (modified 30 -minute battery: Controlled Oral Word Association test; Hopkins Verbal Learning Test-Revised [HVLT-R] trials 1, 2, and 3; digit symbol coding from the Wechsler Adult Intelligence Scale III [WAIS III]; Forward and Backward Digit Span test; Benton Judgment of Line Orientation test, form V; HVLT-R trial 4 and recognition; semantic fluency [Animal Naming test]; Boston Naming Test [BNT; 15-item short form]) at Day 90
• Ambulatory performance (as measured by walking speed) at Day 90
• Center for Epidemiologic Studies-Depression (CES-D)
• Quality of life (European Quality of Life [EQ-5D] questionnaire) at Day 90
• Stroke Impact Scale-16 (SIS-16) at Day 90

3. STUDY DESIGN

3.1 DESCRIPTION OF STUDY

1. One dose of alteplase IV (not to exceed 90 mg ) and one dose of oral aspirin placebo, OR
2. One dose of IV alteplase placebo and one dose of oral aspirin 325 mg (Figure 1).

3.2 LENGTH OF STUDY

3.3 END OF STUDY

3.3.1 Number of Patients

3.4 RATIONALE FOR STUDY DESIGN

• Consistent with the currently approved indication in the alteplase USPI: Treatment with alteplase in PRISMS will occur in otherwise eligible AIS patients within 3 hours from the last known well time.
• Conduct of a large, multicenter study: The Sponsor plans to enroll 948 patients across approximately 75 sites in North America. (For comparison, the two NINDS trials enrolled a total of 624 patients.)
• Multiple endpoints involving different events: In addition to the primary efficacy endpoint of mRS at Day 90, which measures disability, secondary endpoints at Day 90 will include an ordinal mRS assessment and global favorable recovery, as calculated using the Global Outcome Measure derived from the mRS, NIHSS, BI, and GOS.

3.4.1 Rationale for Alteplase Dosage

3.4.2 Rationale for Patient Population

1. An NIHSS score is commonly used as an exclusion criterion for many current AIS studies, suggesting that these patients are underrepresented in current stroke research and are treated differently by the stroke community, as shown in Table 2.
2. The largest retrospective analysis of mild stroke from the Get With the Guidelines registry included 29,200 stroke patients who did not receive alteplase due to mild or improving symptoms. This analysis found that of patients with mild or rapidly improving stroke who did not receive alteplase (and had a recorded NIHSS score) had an initial NIHSS score (Smith et al. 2011).

3.4.3 Rationale for Control Group

3.5 OUTCOME MEASURES

3.5.1 Efficacy Outcome Measures

• A favorable functional outcome, defined by an mRS score of 0 or 1 at Day 90 post-randomization
• All mRS assessments will be made by investigators blinded to treatment assignment who are trained and certified in mRS administration.

• Ordinal mRS
• Global favorable recovery (Global Outcome Measure derived from mRS 0-1, NIHSS 0-1, BI , and GOS=1)

3.5.2 Safety Outcome Measures

• Incidence of sICH within 36 hours (primary safety assessment)
  sICH is defined as any neurological decline attributed to new ICH seen on imaging by the investigator. New ICH seen on imaging will be later confirmed on independent reading by blinded central study radiologists.
• Any ICH within 36 hours
• Overall mortality within 90 days
• Stroke-related and neurological deaths within 90 days
• Incidence, severity, and spectrum of all AEs and SAEs

Symptomatic Intracranial Hemorrhage

3.5.3 Exploratory Outcome Measures

• NIHSS at Day 90
• Instrumental activities of daily living, as measured by the BI at Day 90
• GOS at Day 90
• Stroke recurrence (based on AE monitoring) within 90 days
• Cognition and behavior (modified 30 -minute battery: Controlled Oral Word Association test; Hopkins Verbal Learning Test-Revised [HVLT-R] trials 1, 2, and 3; digit symbol coding from the Wechsler Adult Intelligence Scale III [WAIS III]; Forward and Backward Digit Span test; Benton Judgment of Line Orientation test, form V; HVLT-R trial 4 and recognition; semantic fluency [Animal Naming test]; Boston Naming Test [BNT 15-item short form]) at Day 90
• Ambulatory performance (as measured by walking speed) at Day 90
• Depression (CES-D score) at Day 90
• Quality of life (EQ-5D questionnaire) at Day 90
• SIS-16 at Day 90

4. MATERIALS AND METHODS

4.1 PATIENTS

4.1.1 Inclusion Criteria

• Age years (no upper age limit)
• Mild ischemic stroke defined as the most recent pre-treatment NIHSS score of and determined to be not clearly disabling by the investigator. This includes patients with persistently mild deficits as well as those who improve to a pre-treatment NIHSS score (also known as RISS).
• Study treatment can be initiated within 3 hours of last known well time without stroke symptoms (i.e., last seen normal).
• Signed informed consent prior to initiation of any study-specific procedure or treatment. The patient or the patient's legally authorized representative must be able to provide written informed consent and understand the potential risks and benefits from study enrollment and treatment.

4.1.2 Exclusion Criteria

• CT or MRI findings consisting of one of the following:
• CT with clear large hypodensity that is greater than one-third middle cerebral artery (MCA) territory (or greater than 100 cc if not in MCA territory),
• MRI with clear large hyperintensity on concurrent diffusion-weighted (DW) and fluid-attenuated inversion recovery (FLAIR) that is greater than one-third MCA territory (or greater than 100 cc if not in MCA territory),
• Imaging lesion consistent with acute hemorrhage of any degree, OR
• Evidence of intraparenchymal tumor
• Disability prior to the presenting stroke (historical mRS score )
• Standard contraindications to IV alteplase for patients treated within 3 hours of symptom onset, including:
• Head trauma or previous stroke within the previous 3 months
• Myocardial infarction within the previous 3 months
• Gastrointestinal or urinary tract hemorrhage within the previous 21 days
• Major surgery within the previous 14 days
• Arterial puncture at a non-compressible site within the previous 7 days
• Any history of ICH with the exception of <5 chronic microbleeds on MRI
• Elevated blood pressure (systolic or diastolic ), or the use of aggressive measures (use of more than two intravenous agents to lower blood pressure) to achieve blood pressure within acceptable parameters
• Treatment with unfractionated heparin within the last 48 hours and activated partial thromboplastin time (aPTT) outside of the normal range as specified by the center's local laboratory
• Blood glucose
• International normalized ratio (INR) (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Platelet count of (Note: This does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (including novel oral anticoagulants [e.g., dabigatran, rivaroxaban, apixaban, edoxaban]) within the last 48 hours
• Treatment with a low-molecular-weight heparin (e.g., dalteparin, enoxaparin) within the last 48 hours
• Allergic reactions to study drug, aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs)
• Females of childbearing age who are known to be pregnant and/or lactating, or who have a positive pregnancy test on admission
• Inability to swallow, which would prevent oral intake of aspirin or aspirin placebo tablet
• Other serious, advanced, or terminal illness that would confound the clinical outcome at 90 days
• Current or recent (within 3 months) participation in another investigational drug treatment protocol
• Anticipated inability to obtain 3-month follow-up assessments
• Previous enrollment in PRISMS
• Any other condition that the investigator feels would pose a significant hazard to the patient if treatment with alteplase is initiated

4.2 METHOD OF TREATMENT ASSIGNMENT AND BLINDING

Step Forward Randomization

1. IWRS will assign a patient ID to the currently treated patient, which will be correlated to the drug kit ID previously labeled as "Use Next," via the randomization visit record.
2. IWRS will assign a new pair of drug kit IDs for the next patient that becomes eligible at that site to be labeled as "Use Next."

Study Unblinding

4.3 STUDY TREATMENT

4.3.1 Formulation, Packaging, and Handling

4.3.1.1 Alteplase

4.3.1.2 Alteplase Placebo

4.3.1.3 Aspirin

4.3.1.4 Aspirin Placebo

4.3.2 Dosage, Administration, and Compliance

4.3.2.1 Alteplase

4.3.3 Investigational Medicinal Product Accountability

4.3.4 Investigational Medicinal Product

4.3.4.1 Alteplase and Placebo Test Product

Comparator

4.3.4.2 Non-investigational Medicinal Products

Comparator

Comparator

4.3.5 Post-Trial Access to Alteplase

4.4 CONCOMITANT THERAPY

4.4.1 Permitted Therapy

4.4.2 Prohibited Therapy

• Treatment with unfractionated heparin within the last 48 hours and aPTT outside of the normal range as specified by the center's local laboratory
• Treatment with a direct thrombin inhibitor or factor Xa inhibitor (including novel oral anticoagulants [e.g., dabigatran, rivaroxaban, apixaban, edoxaban]) within the last 48 hours
• Treatment with a low-molecular-weight heparin (e.g., dalteparin, enoxaparin) within the last 48 hours
• Treatment with warfarin and INR (Note: INR does not need to be verified prior to randomization if there is no clinical suspicion of abnormality.)

4.5 STUDY ASSESSMENTS

4.5.1 Description of Study Assessments

4.5.1.1 Informed Consent Forms and Screening Log

4.5.1.2 Medical History and Demographic Data

4.5.1.3 Neurological Examinations

4.5.1.4 Vital Signs

4.5.1.5 Laboratory Assessments

• Complete blood count without differential
• Serum glucose
• Coagulation (INR, aPTT)
• Pregnancy test (serum or urine) for women of childbearing potential including those who have had a tubal ligation

• Complete blood count without differential
• Serum glucose
• Coagulation values (INR, aPTT)
• Pregnancy test for women of childbearing potential including those who have had a tubal ligation

4.5.1.6 Other Disease-Specific Assessments

4.5.2 Patient-Reported Outcomes

4.6 TIMING OF STUDY ASSESSMENTS

4.6.1 Screening/Baseline (Visit 1)

• Medical history
• Demographics
• Neurological examination
• Vital signs
• Complete blood count without differential
• Coagulation status
• Pregnancy test (serum or urine)
• Serum blood glucose
• Non-contrast CT scan or MRI, including DW MRI, either SW or GRE, and FLAIR images
• NIHSS score (Note: This must be performed by an NIHSS-certified practitioner; see Appendix 7)
• Concomitant medications

4.6.2 Visit 2 (22 to Hours after Treatment Initiation)

4.6.3 Visit 3 (Day 5 or Discharge from Hospital, if Sooner than Day 5)

4.6.4 Visit 4 (Day Days)

4.6.5 Visit 5 (Day Days]/Study Completion)

• NIHSS score (Appendix 7)
• Patient survival
• mRS (Appendix 8)
• GOS (Appendix 9)
• BI (Appendix 10)
• EQ-5D (Appendix 4)
• SIS-16 (Appendix 5)
• CES-D (Appendix 6)
• Cognitive assessments (Appendix 11)
• Controlled Oral Word Association test
• HVLT-R trials 1, 2, and 3
• Digit symbol coding from the WAIS III
• Forward and Backward Digit Span test
• Benton Judgment of Line Orientation test, form V
• HVLT-R trial 4 and recognition
• Animal Naming test

• BNT 15-item short form

• Walking speed (Appendix 12)
• Concomitant medications
• SAEs and certain AEs (See Section 5.3.1)

4.6.6 Early Discontinuation

4.7 PATIENT, TREATMENT, STUDY, AND SITE DISCONTINUATION

4.7.1 Patient Discontinuation

• Patient withdrawal of consent at any time
• Any medical condition that the investigator or Sponsor determines may jeopardize the patient's safety if he or she continues in the study
• Investigator or Sponsor determines it is in the best interest of the patient
• Patient non-compliance, specifically defined as unwillingness to participate in a 3-month assessment of neurological status and function

4.7.2 Study Treatment Discontinuation

• Anaphylactoid reaction (including angioedema)
• Serious bleeding (not controllable by local pressure) at puncture site or serious bleeding in a critical location (e.g., intracranial, gastrointestinal, retroperitoneal, pericardial)

4.7.3 Study and Site Discontinuation

• The incidence or severity of AEs in this or other studies indicates a potential health hazard to patients.
• Patient enrollment is unsatisfactory
• A pre-specified boundary at the interim analysis was crossed

• Excessively slow recruitment
• Poor protocol adherence
• Inaccurate or incomplete data recording
• Non-compliance with the International Conference on Harmonisation guideline for Good Clinical Practice
• No study activity (i.e., all patients have completed study assessments and all obligations have been fulfilled)

5. ASSESSMENT OF SAFETY

5.1 SAFETY PLAN

5.1.1 Risk of Bleeding

• The incidence of ICH, especially symptomatic ICH, in patients with AIS is higher in alteplase-treated patients than placebo-treated patients in published studies (for detailed information, see the alteplase USPI).

Management of Bleeding

5.1.2 Risk of Allergic Reactions

Management of Allergic Reaction

5.2 SAFETY PARAMETERS AND DEFINITIONS

5.2.1 Adverse Events

• Any unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal product, whether or not considered related to the medicinal product
• Any new disease or exacerbation of an existing disease (a worsening in the character, frequency, or severity of a known condition), except as described in Section 5.3.3.9
• Recurrence of an intermittent medical condition (e.g., headache) not present at baseline
• Any deterioration in a laboratory value or other clinical test (e.g., electrocardiogram, X-ray) that is associated with symptoms or leads to a change in study treatment or concomitant treatment or discontinuation from study drug

5.2.2 Serious Adverse Events (Immediately Reportable to the Sponsor)

• Is fatal (i.e., the AE actually causes or leads to death)
• Is life-threatening (i.e., the AE , in the view of the investigator, places the patient at immediate risk of death)

• Requires or prolongs inpatient hospitalization (see Section 5.3.3.9)
• Results in persistent or significant disability/incapacity (i.e., the AE results in substantial disruption of the patient's ability to conduct normal life functions)
• Is a congenital anomaly/birth defect in a neonate/infant born to a mother exposed to study drug
• Is a significant medical event in the investigator's judgment (e.g., may jeopardize the patient or may require medical/surgical intervention to prevent one of the outcomes listed above)

5.2.3 Non-Serious Adverse Events of Special Interest (Immediately Reportable to the Sponsor)

• sICH events, if not already reported as an SAE (for a list of preferred terms for ICH see Appendix 13)
• Stroke recurrence: report if the AE resulted in a substantial disruption of a person's ability to conduct normal life functions (i.e., the AE resulted in a significant, persistent, or permanent change; impairment; or damage or disruption in the patient's body function/structure, physical activities, and/or quality of life.
• In addition, Suspected Transmission of an Infectious Agent via a Medicinal Product (STIAMP) by the study drug in a Genentech-sponsored trial qualifies as an AESI and requires immediate reporting to the Sponsor.

5.3 METHODS AND TIMING FOR CAPTURING AND ASSESSING SAFETY PARAMETERS

5.3.1 Adverse Event Reporting Period

• All SAEs
• Non-serious ICHs
• Non-serious AESIs
• All AEs that resulted in withdrawal from the study

5.3.2 Assessment of Severity of Adverse Events

5.3.3 Assessment of Causality of Adverse Events

• Temporal relationship of event onset to the initiation of study drug
• Course of the event, considering especially the effects of dose reduction, discontinuation of study drug, or reintroduction of study drug (as applicable)
• Known association of the event with the study drug or with similar treatments
• Known association of the event with the disease under study
• Presence of risk factors in the patient or use of concomitant medications known to increase the occurrence of the event
• Presence of non-treatment-related factors that are known to be associated with the occurrence of the event

Table 5 Causal Attribution Guidance

5.3.3.1 Diagnosis versus Signs and Symptoms

5.3.3.2 Adverse Events Occurring Secondary to Other Events

• If vomiting results in mild dehydration with no additional treatment in a healthy adult, only vomiting should be reported on the eCRF.
• If vomiting results in severe dehydration, both events should be reported separately on the eCRF .
• If a severe gastrointestinal hemorrhage leads to renal failure, both events should be reported separately on the eCRF.
• If dizziness leads to a fall and consequent fracture, all three events should be reported separately on the eCRF.
• If neutropenia is accompanied by an infection, both events should be reported separately on the eCRF.

5.3.3.3 Persistent or Recurrent Adverse Events

5.3.3.4 Abnormal Laboratory Values

• Is accompanied by clinical symptoms
• Results in a change in study treatment (e.g., dosage modification, treatment interruption, or treatment discontinuation)

Alteplase-Genentech, Inc.

• Results in a medical intervention (e.g., potassium supplementation for hypokalemia) or a change in concomitant therapy
• Is clinically significant in the investigator's judgment

5.3.3.5 Abnormal Vital Sign Values

• Is accompanied by clinical symptoms
• Results in a change in study treatment (e.g., dosage modification, treatment interruption, or treatment discontinuation)
• Results in a medical intervention or a change in concomitant therapy
• Is clinically significant in the investigator's judgment

5.3.3.6 Deaths

5.3.3.7 Preexisting Medical Conditions

5.3.3.8 Lack of Efficacy or Worsening of Acute Ischemic Stroke

5.3.3.9 Hospitalization or Prolonged Hospitalization

• Hospitalization for respite care
• Hospitalization for a preexisting condition, provided that all of the following criteria are met:
• The hospitalization was planned prior to the study or was scheduled during the study when elective surgery became necessary because of the expected normal progression of the disease.
• The patient has not suffered an AE.

5.3.3.10 Adverse Events Associated with an Overdose or Error in Drug Administration

5.3.3.11 Patient-Reported Outcome Data

5.4 IMMEDIATE REPORTING REQUIREMENTS FROM INVESTIGATOR TO SPONSOR

• SAEs (see Section 5.4.2 for further details)
• Non-serious AESIs (see Section 5.4.2 for further details)
• Pregnancies (see Section 5.4.3 for further details)

• New signs or symptoms or a change in the diagnosis
• Significant new diagnostic test results
• Change in causality based on new information
• Change in the event's outcome, including recovery
• Additional narrative information on the clinical course of the event

5.4.1 Emergency Medical Contacts

Medical Monitor Contact Information

5.4.2 Reporting Requirements for Serious Adverse Events and Non-Serious Adverse Events of Special Interest

5.4.3 Reporting Requirements for Pregnancies

5.4.3.1 Pregnancies in Female Patients

5.4.3.2 Congenital Anomalies/Birth Defects and Abortions

5.5 FOLLOW-UP OF PATIENTS AFTER ADVERSE EVENTS

5.5.1 Investigator Follow-Up

5.5.2 Sponsor Follow-Up

5.6 POST-STUDY ADVERSE EVENTS

5.7 EXPEDITED REPORTING TO HEALTH AUTHORITIES, INVESTIGATORS, INSTITUTIONAL REVIEW BOARDS, AND ETHICS COMMITTEES

• Alteplase USPI

6. STATISTICAL METHODS

6.1 DETERMINATION OF SAMPLE SIZE

6.2 PRIMARY ANALYSIS

6.3 SAFETY ANALYSIS

6.4 EXPLORATORY ANALYSES

• Age (<65 vs. )
• Pre-treatment NIHSS score ( vs. 3-5)
• Last known well time to treatment ( vs. hours)
• Stroke subgroup (RISS vs. non-RISS)

6.5 INTERIM ANALYSIS

6.6 MISSING DATA HANDLING

7. DATA COLLECTION AND MANAGEMENT

7.1 DATA QUALITY ASSURANCE

7.2 ELECTRONIC CASE REPORT FORMS

7.3 SOURCE DATA DOCUMENTATION

7.4 USE OF COMPUTERIZED SYSTEMS

7.5 RETENTION OF RECORDS

8. ETHICAL CONSIDERATIONS

8.1 COMPLIANCE WITH LAWS AND REGULATIONS

8.2 INFORMED CONSENT

8.3 INSTITUTIONAL REVIEW BOARD OR ETHICS COMMITTEE

8.4 CONFIDENTIALITY

8.5 FINANCIAL DISCLOSURE

9. STUDY DOCUMENTATION, MONITORING, AND ADMINISTRATION

9.1 STUDY DOCUMENTATION

9.2 PROTOCOL VIOLATIONS

9.3 SITE INSPECTIONS

9.4 ADMINISTRATIVE STRUCTURE

• Provide recommendations regarding changes in the study conduct
• Review results of the final analyses for primary and secondary endpoints
• Participate in the drafting and publishing of final study results

• Review all accumulated safety data at interim analysis
• Review efficacy data analysis performed for interim analysis for consideration of potential discontinuation of the trial for futility
• Make recommendation to the Sponsor as to if it is appropriate to discontinue the study after assessing the interim efficacy and safety data in aggregate
• Determine if the study should continue after review of interim analysis results

9.5 PUBLICATION OF DATA AND PROTECTION OF TRADE SECRETS

9.6 PROTOCOL AMENDMENTS

10. REFERENCES

Appendix 1
Schedule of Assessments

Appendix 1 (cont.)
Schedule of Assessments

Appendix 1 (cont.) Schedule of Assessments

Alteplase-Genentech, Inc.

Appendix 2
Alteplase Administration

Administration of bolus

• Remove from vial using a syringe and needle,
• Remove from port (second injection site) on infusion line after infusion set is primed, or
• Program infusion pump to deliver bolus at infusion initiation

Appendix 3
Reconstitution of Vials

Step 1:

Step 2:

Step 3:

Step 4:

Step 5:

Appendix 4
European Quality of Life-5D (EQ-5D) Questionnaire

Mobility

Pain/Discomfort

I have no pain or discomfort

I have moderate pain or discomfort

I have extreme pain or discomfort

Anxiety/Depression

am not anxious or depressed

am moderately anxious or depressed

I am extremely anxious or depressed

Appendix 4 (cont.)
European Quality of Life-5D (EQ-5D) Questionnaire

Appendix 6
Center for Epidemiologic Studies, Depression (CES-D) Scale, NIMH

Appendix 7 (cont.) National Institutes of Health Stroke Scale (NIHSS)

Appendix 7 (cont.) National Institutes of Health Stroke Scale (NIHSS)

Appendix 7 (cont.) National Institutes of Health Stroke Scale (NIHSS)

Appendix 8 Modified Rankin Scale (mRS)

Appendix 9 Glasgow Outcome Scale (GOS)

References

Appendix 10
Barthel Index (BI)

Activity

FEEDING

Appendix 10 (cont.) Barthel Index (BI)

The Barthel ADL Index: Guidelines

1. The index should be used as a record of what a patient does, not as a record of what a patient could do.
2. The main aim is to establish degree of independence from any help, physical or verbal, however minor and for whatever reason.
3. The need for supervision renders the patient not independent.
4. A patient's performance should be established using the best available evidence. Asking the patient, fiends/relatives and nurses are the usual sources, but direct observation and common sense are also important. However direct testing is not needed.
5. Usually the patient's performance over the preceding hours is important, but occasionally longer periods will be relevant.
6. Middle categories imply that the patient supplies over 50 per cent of the effort.
7. Use of aids to be independent is allowed.

Appendix 11 Cognitive and Behavioral Assessments

A. Controlled Oral Word Association Test

Appendix 11 (cont.)
Cognitive and Behavioral Assessments

B . Hopkins Verbal Learning Test-Revised (HVLT-R)

Form 1
Semantic Categories: Four-Legged Animals, Precious Stones, Human Dwellings

Appendix 11 (cont.) Cognitive and Behavioral Assessments

Delayed Recognition Trial Instructions

Appendix 11 (cont.) Cognitive and Behavioral Assessments

Appendix 11 (cont.) Cognitive and Behavioral Assessments

D. Forward and Backward Digit Span Test

FORWARD AND BACKWARD DIGIT SPAN TEST

DIGIT SPAN (FORWARD)*

DIGIT SPAN (BACKWARD)*

Appendix 11 (cont.)
Cognitive and Behavioral Assessments

E. Benton Judgment of Line Orientation

Benton Judgment Of Line Orientation - Form V

TEST ITEMS

Appendix 11 (cont.) Cognitive and Behavioral Assessments

F. Animal Naming Test

ANIMAL NAMING

Appendix 11 (cont.) Cognitive and Behavioral Assessments

Appendix 11 (cont.)
Cognitive and Behavioral Assessments

G. Boston Naming Test (BNT) 15-Item Short Form

SHORT FORM

Appendix 11 (cont.) Cognitive and Behavioral Assessments

Appendix 11 (cont.) Cognitive and Behavioral Assessments

Summary of Scores

1. Number of spontaneously given correct responses
2. Number of stimulus cues given
3. Number of correct responses following a stimulus cue
4. Number of phonemic cues
5. Number of correct responses following the phonemic cue
6. Number of multiple choices given
7. Number of correct choices

Appendix 12
10 Meter Walk Test

Physical Assistance Provided During Testing:

Test Administration:

1. Instruct the subject in the goal of the 10 meter walk test while the subject is seated:
   "You are going to walk a distance of about feet. We will repeat this distance four times. The first two times will be completed at your comfortable pace, the final two times you will walk as quickly and safely as you can. Do you have any questions?"
2. Demonstrate where you want the subject to walk.
3. Walk the subject to the start line (0 meters). Provide the subject with the following instructions:
   "You will walk at a comfortable pace to the chair." (DO NOT refer to the tape on the floor.) The start command is "Ready and Go".
4. When you and the subject are ready, say "Ready and Go". If the subject starts too early, start again.

Appendix 12 (cont.) 10 Meter Walk Test

5. Instructions for Recording Time:
   □ START the stopwatch when the subject's first foot crosses the plane of the 2 meter line
   □ STOP the stopwatch when the subject's first foot crosses the plane of the 12 meter line.
   □ Have the subject continue walking until he/she reaches the chair after the 14 meter line.
   □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance
   "Comfortable" Pace Trial 1 line on the 10 Meter Walk Test Source Document.
   □ The subject can rest, if needed, in the chair near the 14 meter line.
6. When the subject is ready, have them repeat the SAME PROCEDURE except they will start from the 14 meter line and end at 0 meter line.
   □ START the stopwatch when the subject's first foot crosses the plane of the 12 meter line
   □ STOP the stopwatch when the subject's first foot crosses the plane of the 2 meter line.
   □ Have the subject continue walking until he/she reaches the chair after the 0 meter line.
   □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance on the "Comfortable" Pace Trial 2 line on the 10 Meter Walk Test Source Document.
   □ The subject can rest, if needed, in the chair near the 0 meter line.
7. Subject Instructions for the last 2 trials:
   "You are going to walk the same distances for two additional trials as quickly and as safely as you can. Do you have any questions?"
8. When the subject is ready, walk the subject to the start line (0 meters). Provide the subject with the following instructions:
   "You will walk as quickly and as safely as you can to the chair." (Use an appropriate descriptor for chair/location, but DO NOT refer to the tape on the floor.) The start command is "Ready and Go".
9. When you and the subject are ready, say "Ready and Go". If the subject starts too early, have them start again.

Appendix 12 (cont.) 10 Meter Walk Test

10. Instructions for Recording Time:
    □ START the stopwatch when the subject's first foot crosses the plane of the 2 meter line
    □ STOP the stopwatch when the subject's first foot crosses the plane of the 12 meter line.
    □ Have the subject continue walking until he/she reaches the chair after the 14 meter line.
    □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance on the "As Fast As Possible" Pace Trial 1 line on the 10 Meter Walk Test Source Document.
    □ The subject can rest, if needed, in the chair near the 14 meter line.
11. When the subject is ready, have them repeat the SAME PROCEDURE except they will start from the 14 meter line and end at 0 meter line.
    □ START the stopwatch when the subject's first foot crosses the plane of the 12 meter line
    □ STOP the stopwatch when the subject's first foot crosses the plane of the 2 meter line.
    □ Have the subject continue walking until he/she reaches the chair after the 0 meter line.
    □ Record (in seconds to the hundredths) the time it took for the subject to walk the ten meter distance on the "As Fast As Possible" Pace Trial 2 line on the 10 Meter Walk Test Source Document.
    □ The subject can rest, if needed, in the chair near the 0 meter line.
12. Record the assistive device used and the Functional Ambulation Category (FAC) on the 10 Meter Walk Test Source Document.

REFERENCES:

Appendix 13
Preferred Terms for Intracranial Hemorrhage

• Basal ganglia hemorrhage
• Brain stem hematoma
• Brain stem hemorrhage
• Brain stem microhemorrhage
• Cerebellar hematoma
• Cerebellar hemorrhage
• Cerebellar microhemorrhage
• Cerebral arteriovenous malformation hemorrhagic
• Cerebral hematoma
• Cerebral hemorrhage
• Cerebral microhemorrhage
• Epidural hemorrhage
• Extradural hematoma
• Hemorrhage intracranial
• Hemorrhagic cerebral infarction
• Hemorrhagic stroke
• Hemorrhagic transformation stroke
• Intracranial hematoma
• Intraventricular hemorrhage
• Meningorrhagia
• Pituitary hemorrhage
• Putamen hemorrhage
• Subarachnoid hemorrhage
• Subdural hematoma
• Subdural hemorrhage
• Thalamus hemorrhage
• Traumatic intracranial hemorrhage

Appendix 14

World Health Organization (WHO) Toxicity Grading Scale for Determining the Severity of Adverse Events

World Health Organization (WHO) Toxicity Grading Scale for Determining the Severity of Adverse Events

World Health Organization (WHO) Toxicity Grading Scale for Determining the Severity of Adverse Events

Appendix 14 (cont.)

World Health Organization (WHO) Toxicity Grading Scale for Determining the Severity of Adverse Events

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1. Alteplase-Genentech, Inc.
   Protocol ML29093, Version 1 14
2. Alteplase-Genentech, Inc.
   Protocol ML29093, Version 1 61
3. Alteplase-Genentech, Inc.
   Protocol ML29093, Version 1
4. 1AE/SAE collection should be started as soon as study drug administration (bolus) is initiated.
   Alteplase-Genentech, Inc.
   Protocol ML29093, Version 2 51
5. Alteplase-Genentech, Inc.
   Protocol ML29093, Version 2
   73
6. SCORING: zero for answers in the first column, 1 for answers in the second column, 2 for answers in the third column, 3 for answers in the fourth column. The scoring of positive items is reversed. Possible range of scores is zero to 60 , with the higher scores indicating the presence of more symptomatology.
7. *Wechsler, D (1987) Wechsler Memory Scale-Revised Manual. San Antonio, TX Psychological Corporation.
8. Alteplase-Genentech, Inc.
   22/Protocol ML29093, Version 3
9. Alteplase-Genentech, Inc.
   36/Protocol ML29093, Version 3
10. Alteplase-Genentech, Inc.
    39/Protocol ML29093, Version 3
11. 1AE/SAE collection should be started as soon as study drug administration (bolus) is initiated.
    Alteplase-Genentech, Inc.
    43/Protocol ML29093, Version 3
12. Alteplase-Genentech, Inc.
    58/Protocol ML29093, Version 3
13. Alteplase-Genentech, Inc.
    60/Protocol ML29093, Version 3
14. Alteplase-Genentech, Inc.
    61/Protocol ML29093, Version 3
15. Alteplase-Genentech, Inc.
    62/Protocol ML29093, Version 3
16. Alteplase-Genentech, Inc.
    66/Protocol ML29093, Version 3
17. Abbreviated Clinical Study Report: Alteplase-Genentech, Inc. 620/aCSR ML29093
18. Alteplase-Genentech, Inc.
    88/Protocol ML29093, Version 3
19. Alteplase-Genentech, Inc.
    90/Protocol ML29093, Version 3
20. Wechsle1, D (1987), Wechsler Memory Scale-Rev ised Mamal San Antonio, TX. Psychological Conporalion
21. Alteplase-Genentech, Inc.
    92/Protocol ML29093, Version 3
22. Alteplase-Genentech, Inc.
    93/Protocol ML29093, Version 3