Deferiprone for Ruptured Brain Aneurysm

Subjects should be aged 18-70, presents with aneurysmal SAH, that requires the placement of a ventriculostomy (EVD) and coiling or stent assisted coiling of the aneurysm.

Inclusion criteria:

1. Age greater or equal to 18 and less or equal to 70 years

2. Historical modified Rankin Scale Score (mRS) 0-1 (pre-subarachnoid hemorrhage onset)

3. World Federation of Neurosurgical Societies SAH Scale (WFNS) 50 grade lesser or equal to 3, due to a spontaneous SAH attributed to a ruptured cerebral aneurysm.

• Initial WFNS grade may be determined at admission or enrollment, preferably after the patient's mental status has been optimized by resuscitation and interval treatment of hydrocephalus (i.e., placement of intraventricular catheter [EVD]) or reversal/wearing-off of sedating medications used commonly during patient transfers and transport or procedure related anesthesia.

4. Admission head CT showing modified Fisher grade 1-4 due to aSAH primarily in the supratentorial space. The Modified Fisher CT rating scale is: Grade 1 (minimal or diffuse thing SAH without intraventricular hemorrhage); Grade 2 (minimal or thin SAH with intraventricular hemorrhage), Grade 3 (thick cisternal clot without intraventricular hemorrhage), Grade 4 (thick cisternal clot with intraventricular hemorrhage)

5. Location and pattern of the SAH must have the majority of the SAH in the supratentorial space caused by either an intradural anterior circulation aneurysm or a basilar apex/posterior circulation aneurysm with primarily supratentorial hemorrhage extension. Angiographic location of the aneurysm will be confirmed by catheter digital subtraction angiography usually obtained during the coil embolization procedure.

6. Onset of symptoms of aSAH (ictus) occurred < 24 hours prior to presentation at the treating facility.

7. Initiation of aneurysm securement procedure occurred < 48 hours from the ictus and less than 12 hours from admission to the treating facility.

8. In subjects where the exact time of the ictus is uncertain, an estimated time of ictus may be assigned and that time will be used for the inclusion criteria above assuming the estimation is deemed to be reasonably reliable [i.e., actual time is highly likely to be within 6 hours of estimated time].

9. All aneurysm(s) suspected to be responsible for the hemorrhage or potentially responsible for the hemorrhage must be secured in the following manner prior to enrollment: endovascular Coil Embolization with a post-embolization Raymond-Roy Score of 1 (Complete) or 2 (Residual Neck) 52

10. Ability to screen the patient and obtain head CT and CT perfusion on admission and follow after recovering from anesthesia following the aneurysm coiling procedure, the patient must remain a WFNS SAH grade less or equal to 3 without evidence of a significant new focal neurological deficit including monoparesis / monoplegia, hemiparesis / hemiplegia, or receptive, expressive or global aphasia. New minor cranial nerve defect without any other new findings is permissible. If a national institute of health stroke scale (NIHSS) score was obtained prior to the aneurysm coiling procedure, a post-coiling (pre-enrollment) NIHSS score must not have increased by 4 points or more and Glasgow coma score must not be decreased by 2 points or less. The clinician should use their best clinical judgment as to whether a significant neurological decline has occurred due to the coiling procedure.

11. Ability to obtain MRI for ischemic changes evaluation, measurement of iron deposition and volume of and hippocampus.

Exclusion Criteria:

1. Angio-negative SAH

2. A likely hemorrhage event within several days prior to admission related hemorrhage ictus due to the increased risk of early vasospasm.

3. Prior sentinel headache with negative CT or prior sentinel headache where the patient did not seek medical attention does not exclude the patient.

4. Surgical clipping of the ruptured aneurysm or any non-ruptured aneurysm on the same admission prior to enrollment.

5. SAH not caused by aneurysm rupture or aneurysm is identified to be traumatic, mycotic, blister or fusiform type by catheter DSA.

6. Any intracranial stent placement or non-coil intra-aneurysmal device (i.e., stent- assisted coiling with Neuroform, Enterprise, LVIS, LVIS Jr, Barrel Stent, Pulse Rider, WEB, LUNA, Medina or a similar device) where the stent device is implanted to treat the ruptured aneurysm and / or antiplatelet therapy is needed.

7. Subject has remaining aneurysm(s) that are untreated and could reasonably be considered a possible alternate cause of the aSAH based on the observed bleeding pattern. Adequate treatment of these aneurysms by coiling embolization would result in the aneurysms no longer causing an exclusion. MRI may be used in some situations to determine that the associated aneurysms did not rupture based on lack of blood seen adjacent to the additional aneurysms.

8. Diagnosis of sepsis or current documented active bacterial or viral infection prior to enrollment. A minor uncomplicated community-acquired urinary tract infection would not be an exclusion but should be treated promptly.

9. New parenchymal hemorrhage or new infarction larger the 15cc in volume, or significant increased mass effect as seen on the post coiling pre-enrollment head CT when compared to baseline admission head CT. New hyperdensity on CT scan related to contrast staining is not an exclusion.

10. Subject developed SAH-induced cardiac stunning prior to enrollment, with an ejection fraction< 40%, or requiring intravenous medications for blood pressure maintenance.

11. Concurrent significant intracranial pathology identified prior to enrollment, including but not limited to, Moyamoya disease, high suspicion or documented CNS vasculitis, severe fibromuscular dysplasia, arteriovenous malformation, arteriovenous fistula, significant cervical or intracranial atherosclerotic stenotic disease (greater or equal to 70%), or malignant brain tumor.

12. Known seizure or epilepsy disorder (diagnosed prior to this aSAH diagnosis) where anti-epileptic medication was previously taken by the patient or have been recommended to be taken by the patient. Childhood seizures that have resolved and no longer require treatment are not part of this exclusion criteria

13. Serious co-morbidities that could confound study results including but not limited to: Multiple Sclerosis, dementia, severe major depression, cancer likely to cause death in 2 years, multi-system organ failure, or any other conditions that could cause any degree of cognitive impairment.

14. Immunosuppression therapy including chronic corticosteroid usage.

15. Remote history of previous ruptured cerebral aneurysm.

16. History of gastrointestinal hemorrhage or major systemic hemorrhage within 30 days, hemoglobin less than 8 g/dL, international normalized ratio greater or equal1.5, severe liver impairment, creatinine > 2.0 mg/dL, or estimated glomerular filtration rate < 60 ml/min.

17. Major surgery (including open femoral, aortic, or carotid surgery) within previous 30 days.

18. Currently pregnant.

19. Contraindication for MRI

20. No hydrocephalus requiring EVD

21. Known hypersensitivity to De or to any of the excipients in the formulation.

22. Past medical history of agranulocytosis.

23. Past medical history of any hematologic conditions requiring transfusion of red blood cells or platelets

24. Active or chronic liver disease.