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A study examining the effects of cooling the body after severe brain injury
ISRCTN ISRCTN34555414
DOI 10.1186/ISRCTN34555414
ClinicalTrials.gov identifier
EudraCT number
Public title A study examining the effects of cooling the body after severe brain injury
Scientific title European Society of Intensive Care Medicine study of therapeutic hypothermia (32 - 35°C) for intracranial pressure (ICP) reduction after traumatic brain injury
Acronym Eurotherm3235Trial
Serial number at source Protocol version 8 dated 9/5/12
Study hypothesis Current hypothesis as of 01/07/2009:
Patients treated with therapeutic hypothermia (32 - 35°C) will have reduced morbidity and mortality rates compared to those receiving standard care alone after traumatic brain injury (TBI).

More information can be found at http://www.eurotherm3235trial.eu

Initial information at time of registration:
Does therapeutic hypothermia (33 - 35°C) reduce death and disability after intracranial hypertension due to traumatic brain injury?

As of 01/07/2009 this record has been extensively updated to reflect recent protocol changes. All changes can be found under the relevant field with the above update date. Please note that at this time, the anticipated trial dates have also been updated; the initial trial dates were as follows:
Anticipated start date: 01/01/2009
Anticipated end date: 30/07/2013

Please note that as of 14/08/2012, this record has been updated extensively. All changes can be found under the relevant field with the above update date.
The following changes were also made:
1. The Scientific title was changed from 'European Society of Intensive Care Medicine study of therapeutic hypothermia (32 - 35°C) for intracranial pressure (ICP) reduction after traumatic brain injury' to 'European study of therapeutic hypothermia (32-35˚C) for intracranial pressure reduction after traumatic brain injury’ '
2. The target number of participants was changed from 1800 to 600
3. The anticipated end date was changed from 07/02/2013 to 31/07/2017
4. France, the Netherlands and Poland were removed from the countries of recruitment, and Belguim, Estonia, Greece, Hungary, India, Ireland, Russian Federation, Spain and United Arab Emirates were added to the countries of recruitment.
Lay summary Not provided at time of registration
Ethics approval All trial centres will seek ethical approval before recruiting patients. Ethical approval has been obtained in both Scotland and England in June 09.
Study design Prospective randomised controlled trial
Countries of recruitment Belgium, Estonia, Germany, Greece, Hungary, India, Ireland, Italy, Russian Federation, Spain, United Arab Emirates, United Kingdom
Disease/condition/study domain Traumatic brain injury complicated by increased intracranial pressure
Participants - inclusion criteria Current inclusion criteria as of 14/08/2012:
1. Believed to be legal age for consent to take part in research, either sex
2. Primary closed traumatic brain injury
3. Raised ICP greater than 20 mmHg for greater than or equal to 5 minutes after first line treatments with no obvious reversible cause e.g. patient position, coughing, inadequate sedation
4. Less than or equal to 10 days from the initial head injury
5. Cooling device or technique available for greater than 48 hours
6. Core temperature greater than or equal to 36°C (at the time of randomisation)
7. An abnormal computed tomography (CT) scan of the brain. This is defined as one that shows haematoma, contusion, swelling, herniation or compressed basal cisterns.

Previous inclusion criteria as of 01/07/2009 and until 14/08/2012:
1. Believed to be legal age for consent to take part in research to 65 years of age, either sex
4. Less than or equal to 72 hours from the initial head injury

Initial information at time of registration (2008):
1. Adults aged 16 - 65 years, both males and females
2. Primary, closed traumatic brain injury
3. An abnormal computed tomography (CT) scan of brain, Marshall grade greater than 1
4. Refractory increased intracranial pressure (ICP) greater than 20 mmHg for at least 30 minutes (refractory to first line interventions including mechanical ventilation, sedation, analgesia ± muscle relaxant, head of bed elevation, with monitoring of CVP and invasive arterial pressure)
5. Core temperature greater than 36°C (at the time of randomisation)
6. Cooling device or technique available for greater than 48 hours
Participants - exclusion criteria Current information as of 01/07/2009:
1. Patient already receiving therapeutic hypothermia treatment
2. Administration of barbiturate infusion prior to randomisation
3. Unlikely to survive for the next 24 hours in the opinion of the ICU Consultant or Consultant Neurosurgeon treating the patient
4. Temperature less than or equal to 34°C at hospital admission
5. Pregnancy

Initial information at time of registration:
1. Patients with bilateral fixed and dilated pupils
2. Unable to monitor ICP or patients with ICP less than 20 mmHg
3. Patients who have received barbiturates prior to randomisation
4. Where there is documented brainstem involvement
5. Moribund condition on admission
Anticipated start date 01/09/2009
Anticipated end date 31/07/2017
Status of trial Ongoing
Patient information material Patient information can be found at http://www.eurotherm3235trial.eu/information/index.phtml
Target number of participants 600
Interventions Current information as of 01/07/2009:
Intervention Group: Usual traumatic brain injury management with therapeutic hypothermia (32 - 35°C) for at least 48 hours. The depth of hypothermia will be dependent on ICP control with a higher ICP warranting a lower target temperature. Hypothermia will be induced rapidly using 20 - 30 ml/kg refrigerated saline (0.9%) over 20 - 30 minutes. Hypothermia will then be maintained by using the cooling technique that is routinely used at each recruiting centre.

Control Group: Usual traumatic brain injury management.

Total duration of follow up: 6 months

Initial information at time of registration:
Intervention group: Traumatic brain injury management (Brain Trauma Foundation guidelines) + hypothermia (33 - 35°C) for 48 hours (at least) and guided by ICP response to slow rewarming at 0.3°C/hour. Each centre will use 20 ml per kg of Hartman's solution at 4°C and then a cooling technique available at that centre (a priori sub group analysis may be effectiveness of device type on outcome) and previous experience of the use of hypothermia will be essential.

Control group: Traumatic brain injury management in line with the Brain Trauma Foundation guidelines.

Total duration of follow-up: 6 months
Primary outcome measure(s) Outcome at 6 months using the extended Glasgow Outcome Score (GOSE) questionnaire
Secondary outcome measure(s) Current information as of 01/07/2009:
1. 6-month mortality rate
2. Intracranial pressure (ICP) control
3. Incidence of Pneumonia across both groups
4. Length of stay in the Intensive Care Unit (ICU) and Hospital
5. Modified Oxford Handicap Scale score at one month, discharge from the randomising hospital or death, whichever occurs first
6. Correlation between the predicted outcome using the modified Oxford handicap scale at hospital discharge and the GOSE Score at 6 months post injury
7. Health economics (dependent on additional external funding)

Other planned analyses:
A priori sub group analysis will be presented testing the relationship between minimisation factors including; age < 45 years, admission post resuscitation GCS motor score <2, time from injury <12 hours and outcome. The analysis will test for interaction effects, and stricter levels of statistical significance (p<0.01) will be sought, reflecting the exploratory nature of these subgroup analyses. Only the primary outcome measure will be used in these analyses.

Other exploratory and observational studies will be conducted by some centres. These sub-studies will be run by local Investigators and will require approval by the trial management and steering committees together with further ethical approval. All sub-studies must also have secured external funding.

Initial information at time of registration:
1. ICP control, assessed by use of additional stage 2 therapies and/or escalation to stage three therapies, episodes of ICP >20 mmHg and duration ICP >20 mmHg
2. Length of intensive care unit (ICU) and hospital stay
3. Head Injury Related Early Outcome Scale (HIREOS) at 21 days
4. Mortality

Other planned analyses:
A priori sub group analysis will be testing the relationship between minimisation factors, including age less than and age older than 45 years, presence of cerebral contusion on CT scanning, admission post resuscitation GCS <5, gender, cooling technology, and outcome. Stricter levels of statistical significance (p <0.01) will be sought, reflecting the exploratory nature of these subgroup analyses. Primary outcome measure only will be used in these analyses.

Other exploratory, observational studies will be conducted by some centres and will include assessment of the genetics of responsiveness to hypothermia (to be lead by Professor Menon), modulation of inflammation (including response to intercurrent infection) and effect upon cerebral vascular autoregulation. There are likely to be other sub-studies run by centre PIs and all will require approval by the steering committee and will have identified external funding.
Sources of funding 1. The European Society of Intensive Care Medicine (Belgium)
2. The National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme
Trial website http://www.eurotherm3235trial.eu
Publications 1. 2011 protocol in http://www.ncbi.nlm.nih.gov/pubmed/21226939
2. 2013 results in: http://www.ncbi.nlm.nih.gov/pubmed/24004918
Contact name Prof  Peter JD  Andrews
  Address Critical Care Unit, Ward 20
Western General Hospital
Crewe Road
  City/town Edinburgh
  Zip/Postcode EH4 2XU
  Country United Kingdom
  Email p.andrews@ed.ac.uk
Sponsor University of Edinburgh and NHS Lothian (UK)
  Address Queen’s Medical Research Institute
Room E106
47 Little France Crescent
  City/town Edinburgh
  Zip/Postcode EH16 4SA
  Country United Kingdom
  Tel +44 (0)131 242 9461
  Fax +44 (0)131 242 9301
  Email marise.bucukoglu@ed.ac.uk
  Sponsor website: http://www.accord.ed.ac.uk
Date applied 30/04/2008
Last edited 06/09/2013
Date ISRCTN assigned 30/05/2008
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