Assessment of the End Point Adjudication Process on the Results of the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trial: A Secondary Analysis.

Key Points Question Is there an advantage to centrally adjudicating clinical trial end points compared with relying on investigator-assessed end points? Findings In this secondary analysis of an international randomized clinical trial of 4881 patients who received clopidogrel bisulphate plus aspirin vs placebo plus aspirin, independent end point adjudication did not substantially change estimates of the primary treatment associations compared with investigator-assessed end points. Meaning Independent end point adjudication may have no clinically meaningful improvement on estimates of treatment associations in studies of transient ischemic attack and minor stroke when masking is well controlled and training is provided.


eAppendix 1. Outcome Event Definitions
Ischemic stroke: An acute focal infarction of the brain or retina (and does not include anterior ischemic optic neuropathy (AION)).

Criteria:
(1) Rapid onset of a new focal neurological deficit with clinical or imaging evidence of infarction and not attributable to a non-ischemic etiology (not associated with brain infection, trauma, tumor, seizure, severe metabolic disease, or degenerative neurological disease); or (2) Rapid worsening of an existing focal neurological deficit that is judged by the Investigator to be attributable to a new infarction. Criteria for symptoms attributable to new infarction may include symptoms that persist and are judged by the investigator to be attributable to new infarction, imaging evidence of infarction or no evidence of a non-ischemic etiology.

Major hemorrhage other than intracranial hemorrhage (life-threatening or non-life-threatening):
A hemorrhagic event, judged to be non-traumatic, that results in intraocular bleeding causing loss of vision, the need for a transfusion of two or more units of red cells or the equivalent amount of whole blood, or the need for hospitalization or prolongation of existing hospitalization. This may include bleeding events related to surgical procedures but not those related to accidental trauma. Lifethreatening hemorrhagic events will be defined as those that are fatal or require use of intravenous inotropic medication to maintain blood pressure, interventional treatment (including surgical, endoscopic or endovascular interventions), or transfusion of four or more units of red cells or the equivalent amount of whole blood. Non-life-threatening hemorrhagic events will be defined as those classified as major hemorrhagic events but not as life-threatening.
Minor hemorrhage other than intracranial hemorrhage: All hemorrhagic events leading to interruption or discontinuation of the study drug but not classifiable as major hemorrhagic events. This may include bleeding events related to surgical procedures but not those related to accidental trauma. O Ischemic stroke: An acute focal infarction of the brain or retina (and does not include anterior ischemic optic neuropathy (AION)). Criteria: (1) Rapid onset of a new focal neurological deficit with clinical or imaging evidence of infarction and not attributable to a non-ischemic etiology (not associated with brain infection, trauma, tumor, seizure, severe metabolic disease, or degenerative neurological disease); or, (2) Rapid worsening of an existing focal neurological deficit that is judged by the Investigator to be attributable to a new infarction. Criteria for symptoms attributable to new infarction may include symptoms that persist and are judged by the investigator to be attributable to new infarction, imaging evidence of infarction or no evidence of a non-ischemic etiology.
O TIA: A neurological deficit of sudden onset, resolving completely, attributed to focal brain or retinal ischemia without evidence of associated acute focal infarction of the brain. Criteria: rapid onset of a focal neurological deficit that is without evidence of acute focal infarction of the brain, and is not attributable to a non-ischemic etiology (brain infection, trauma, tumor, seizure, severe metabolic disease, or degenerative neurological disease).
O Symptomatic hemorrhagic transformation of an ischemic stroke: Any extravascular blood within an area of known acute/subacute infarction which is judged to be nontraumatic, and responsible for neurologic symptoms. To be considered symptomatic, the hemorrhagic transformation must be judged to be partially responsible for the subject's clinical neurologic presentation (i.e., the area of Infarction is not adequate to explain the neurologic deficit, or a secondary neurologic deterioration occurred corresponding to the timing of hemorrhagic transformation). Criteria (must meet both of the following): a. Imaging evidence (by CT or MR) of extravascular blood within the area of infarction. b.
Symptoms judged to be related to the hemorrhagic transformation. Scenarios which may be judged as symptomatic: (i) If blood is already present on imaging at presentation, symptoms are out of proportion to what would be expected for the size and location of the infarct at presentation; (ii) Clinical deterioration, defined by an increase of 4 points or more in the score on the NIHSS or leading to death, occurring after the initial ischemic event, and identified as the result of the hemorrhagic transformation; or (iii) Mass effect secondary to the hemorrhagic transformation causing symptoms.
O Asymptomatic hemorrhagic transformation of an ischemic stroke: Any extravascular blood within an area of known acute/subacute infarct, judged to be nontraumatic, without any related neurologic symptoms. Criteria (must meet both of the following): a. Imaging evidence (by CT or MRI) of extravascular blood within the area of infarct. b.
No symptoms related to the hemorrhagic transformation, or clinical deterioration with less than a 4-point increase in score on the NIHSS judged to be related to the hemorrhagic transformation.
O Symptomatic intracerebral hemorrhage: Any extravascular blood in the brain parenchyma, judged to be nontraumatic, and not in the area of an acute/subacute ischemic infarct, associated with and identified as the predominant cause of new neurologic symptoms (including headache) or death. In the case of a mixed intracranial hemorrhage [Intracerebral Hemorrhage (ICH), Subarachnoid Hemorrhage (SAH, Subdural Hemorrhage (SDH), and/or Intraventricular Hemorrhage (IVH)], the event should be classified according to the primary site of hemorrhage by the judgment of the clinician. For example, if a patient has a large ICH with a small amount of SAH, and the ICH is felt to be the primary site of bleeding, this should be classified as ICH. Criteria: Evidence of hemorrhage in the brain parenchyma demonstrated by head imaging, surgery, or autopsy, which is not in the same territory of an underlying acute or subacute ischemic stroke, and is judged to be associated with any new neurologic symptoms (including headache) or leading to death.
O Asymptomatic intracerebral hemorrhage: An acute extravasation of blood into the brain parenchyma, judged to be nontraumatic, and not in an area of an acute/subacute ischemic infarct, without associated neurologic symptoms or leading to death. In the case of a mixed intracranial hemorrhage (ICH, SAH, SDH and/or IVH), the event should be classified according to the primary site of hemorrhage by the judgment of the clinician. For example, if a patient has a large ICH with a small amount of SAH, and the ICH is felt to be the primary site of bleeding, this should be classified as ICH. Criteria: evidence of hemorrhage in the brain parenchyma demonstrated by head imaging, surgery, or autopsy, which is not in the same territory of an underlying acute or subacute ischemic stroke, and is not judged to be associated with any new neurologic symptoms or leading to death.
O Other symptomatic intracranial hemorrhage: Any extravascular blood within the cranium judged to be nontraumatic, and the predominant cause of the clinical deterioration or that led to death. Other Intracranial Hemorrhage is defined as an acute extravasation of blood into the subarachnoid space, epidural space, subdural space or intraventricular space with associated symptoms (including headache). In the case of a mixed intracranial hemorrhage (ICH, SAH, SDH and/or IVH), the event should be classified according to the primary site of hemorrhage by the judgment of the clinician. For example, if a patient has a large ICH with a small amount of SAH, and the ICH is felt to be the primary site of bleeding, this should be classified as ICH. Criteria: Evidence of hemorrhage in the subarachnoid space, epidural space, or subdural space demonstrated by head imaging, surgery, or autopsy.
O Other asymptomatic intracranial hemorrhage: An acute extravasation of blood into the subarachnoid space, epidural space, subdural space or intraventricular space without associated symptoms, and judged to be nontraumatic. In the case of a mixed intracranial hemorrhage (ICH, SAH, SDH and/or IVH), the event should be classified according to the primary site of hemorrhage by the judgment of the clinician. For example, if a patient has a large ICH with a small amount of SAH, and the ICH is felt to be the primary site of bleeding, this should be classified as ICH. Criteria: Evidence of hemorrhage in the subarachnoid space, epidural space, or subdural space demonstrated by head imaging, surgery, or autopsy. O Major hemorrhage other than intracranial hemorrhage (life-threatening or non-life-threatening): A hemorrhagic event, judged to be nontraumatic, that results in intraocular bleeding causing loss of vision, the need for a transfusion of two or more units of red cells or the equivalent amount of whole blood, or the need for hospitalization or prolongation of existing hospitalization. This may include bleeding events related to surgical procedures but not those related to accidental trauma. Life-threatening hemorrhagic events will be defined as those that are fatal or require use of intravenous inotropic medication to maintain blood pressure, interventional treatment (including surgical, endoscopic or endovascular interventions), or transfusion of four or more units of red cells or the equivalent amount of whole blood. Non-life-threatening hemorrhagic events will be defined as those classified as major hemorrhagic events but not as life-threatening.

O Not related
The temporal relationship between treatment exposure and the adverse event is unreasonable or incompatible and/or adverse event is clearly due to extraneous causes (e.g., underlying disease, environment) O Unlikely (must have 2) • Could readily have been produced by the subject's clinical state, or environmental or other interventions.
• Does not follow known pattern of response to intervention. • Does not reappear or worsen with reintroduction of intervention.
O Possibly (must have 2) • Has a reasonable temporal relationship to intervention.
• Could not readily have been produced by the subject's clinical state or environmental or other interventions.
• Follows a known pattern of response to intervention.
O Probably (must have 3) • Has a reasonable temporal relationship to intervention.
• Could not readily have been produced by the subject's clinical state or have been due to environmental or other interventions.
• Follows a known pattern of response to intervention.
• Disappears or decreases with cessation of intervention.
O Definitely (must have all 4) • Has a reasonable temporal relationship to intervention.
• Could not readily have been produced by the subject's clinical state or have been due to environmental or other interventions.
• Follows a known pattern of response to intervention.
• Disappears or decreases with cessation of intervention and recurs with re-exposure.
General Comments: Name of person who collected these data (not for data entry): Signature of Reviewing Investigator/Date (not for data entry): Page 4 of 5 POINT version 9 13Oct2014