Gharagozli 2017.

Study characteristics
Methods	Study design: prospective, randomised, placebo‐controlled, double‐blind trial Study grouping: parallel group Losses to follow‐up: 25 out of 100 (25%) Follow‐up period: 30 days Trial protocol registration: retrospective ("registered while recruiting", no actual recruitment start date provided)
Participants	Participants were between 45 and 85 years old with a clinically confirmed acute embolic or thrombotic stroke in the territory of the arterial branches of the internal carotid artery. Mean age = 68 ± 11.5 years, approximately men/women: 50/50 The first application of the study medication was within 18 hours poststroke, and the treatment lasted for 4 weeks. Inclusion criteria: people between 45 and 85 years old with a clinically confirmed acute embolic or thrombotic stroke in the territory of the arterial branches of the internal carotid artery Exclusion criteria: complete remission of symptoms within 4 hours after onset; the presence of signs and symptoms of progressive neurological deficits; signs of haemorrhagic stroke or intracranial bleeding; systolic blood pressure ≥ 200 mmHg; diastolic blood pressure ≥ 100 mmHg; signs of stupor or coma (Glasgow Coma Scale score of ≤ 6); convulsions; pupillary oedema; increased intracranial pressure; myocardial infarction; cardiac function deficit; renal or hepatic insufficiency; acute infections; pregnancy; participation in another clinical study. Patients treated with rtPA were not included in the study, and concomitant medication with piracetam or calcium channel blockers was not allowed owing to their purported neuroprotective effects.
Interventions	Acute phase during the first 7 days, the study drug was administered daily as an intravenous infusion for a period of 30 minutes (30 mL Cerebrolysin + 50 mL saline = 80 mL). Then 10 mL intravenously 5 days per week. Unclear whether the daily dose was 10 mL Cerebrolysin or 10 mL of the 30:50 Cerebrolysin Placebo: normal saline, same volume as Cerebrolysin solutions Baseline treatment: 100 mg daily aspirin, pentoxifylline, or low‐dose heparin
Outcomes	All‐cause death (dichotomous outcome) Serious adverse events (dichotomous outcome) Total number of participants with adverse events (dichotomous outcome)
Identification	Sponsorship source: EVER Neuro Pharma GmbH Country: Iran Setting: inpatient (hospital) Comments: a number of study authors were closely involved with EVER Neuro Pharma Conflict of interest statement: JV is a member of the advisory board of EVER Neuro Pharma. SW is an employee of EVER Neuro Pharma. HM is a scientific consultant for EVER Neuro Pharma. The other authors declare that they have no conflict of interest. Corresponding author: Herbert Moessler Institution: COMAMO Lifesciences GmbH Mondseestrasse 34/3, 5310 Mondsee, Austria, Phone: +43 664 4633723, Email: herbert.moessler@comamo.at
Notes	No results posted on trial registration platform.
Risk of bias
Bias	Authors' judgement	Support for judgement
Allocation concealment	Unclear risk	Comment: there is no information about allocation concealment, no central randomisation
Sequence Generation	Low risk	Quote: "Patients were assigned to treatment groups according to a predefined randomization plan by using a block size of 4, a ratio of 1:1, and stratified by study center." Comment: though the described procedure does not fit with any of the criteria for an assessment of low risk of bias, i.e. random number table; using a computer random number generator; coin tossing; shuffling cards or envelopes; throwing dice; drawing of lots; or minimisation, we judged this as low risk because there was a predefined randomisation plan and block randomisation stratified by study centre
Incomplete outcome data All outcomes	High risk	Quote: "A total of 100 patients were enrolled in this study (Cerebrolysin, n=50; placebo, N=50). All patients received at least one dose of the study medication and thus represented the safety analysis data set. One patient in the Cerebrolysin group had no efficacy baseline assessment, and another patient in the Cerebrolysin group did not provide any post‐baseline efficacy data. Thus, the mITT‐LOCF analysis consisted of 98 patients (Cerebrolysin, N=48; placebo, N=50). Of those, 23 patients discontinued participation in the study prematurely: four patients withdrew because of adverse events (AEs) (Cerebrolysin, N=2; placebo, N=2), three patients died in the acute phase due to stroke severity (Cerebrolysin, N=1; placebo, N=2) and another 16 patients were lost to follow‐up after discharge from the hospital (Cerebrolysin, N=12; placebo, N=4). Thus, a total of 75 patients (Cerebrolysin, N=33; placebo, N=42) comprised the data as the available (observed cases; OC) analysis set. Since the percentage of missing values at day 30 was comparatively high (23%), a sensitivity analysis for the primary outcome measure was also performed based on the OC population." Comment: overall attrition = 25 out of 100 ITT or 23 out of 98 who entered. However, attrition in the Cerebrolysin group was high, with only 33/50 ITT or 33/48 analysable (i.e. attrition rates of 34% or 31.25%). Furthermore, the study authors used the 'last observation carried forward' (LOCF) method to fill in the missing data points. There is not a single peer‐reviewed statistical publication that describes general conditions under which LOCF provides a statistically unbiased result.
Blinding of outcome assessors All outcomes	Unclear risk	Quote: "The statistician in charge of randomization was unblinded but was not involved in any other study‐related procedures." Comment: the statistician was not blinded
Selective outcome reporting	Unclear risk	Comment: overall attrition = 25 out of 100 ITT or 23 out of 98 who entered. However, attrition in the Cerebrolysin group was high, with only 33/50 ITT or 33/48 analysable (i.e. attrition rates of 34% or 31.25%). Furthermore, the study authors used the 'last observation carried forward' (LOCF) method to fill in the missing data points. There is not a single peer‐reviewed statistical publication that describes general conditions under which LOCF provides a statistically unbiased result. The study protocol was registered retrospectively.
Blinding of participants and personnel All outcomes	Low risk	Quote: "Patients, investigators and all study personnel were blinded to the treatment allocation ... EVER Neuro Pharma provided the study medication in 10‐ml ampoules labelled appropriately to maintain blinding." Comment: though there was insufficient information to permit a judgement about blinding by outcome, we judged this as low risk of bias
Other sources of bias	High risk	Quote: "Overall, the safety outcome reflected the expected safety and tolerability profile of Cerebrolysin in patients after acute ischemic stroke." Quote: "JV is a member of the advisory board of EVER Neuro Pharma. SW is an employee of EVER Neuro Pharma. HM is a scientific consultant for EVER Neuro Pharma. " Quote: "Acknowledgments: EVER Neuro Pharma GmbH provided the study medication." "Conflict of Interest: JV is a member of the advisory board of EVER Neuro Pharma. SW is an employee of EVER Neuro Pharma. HM is a scientific consultant for EVER Neuro Pharma. The other authors declare that they have no conflict of interest." Quote: "Overall, patients in the placebo groups presented with somewhat milder symptoms according to the NIHSS score (9.1± 4.8; mean ± standard deviation) compared to the Cerebrolysin group (11.1 ± 5.0). Corresponding evidence for a slightly milder patient population in the placebo group was also seen in the mRS score (placebo: 3.4 ± 1.1; Cerebrolysin: 3.9 ± 1.0). Since these baseline group differences reached statistical significance for the NIHSS (MW 0.36, P=0.02) and for the mRS (MW 0.39, P=0.05), an ANCOVA sensitivity analysis was performed by using the baseline score as a covariate to confirm the robustness of the data."