# Randomised, controlled Trial of CT perfusion and angiography compared to CT alone in thrombolysis-eligible acute ischaemic stroke patients: The penumbra and recanalisation acute computed tomography in ischaemic stroke evaluation (PRACTISE) trial

## TL;DR

A study found that using advanced CT scans in stroke patients reduced the use of clot-busting drugs without affecting treatment times or outcomes.

## Contribution

The study is the first to show that multimodal CT reduces thrombolysis use in acute stroke patients without worsening clinical outcomes.

## Key findings

- Fewer patients in the multimodal CT group received thrombolysis compared to the NCCT group.
- Treatment decision times and clinical outcomes were similar between the two groups.
- Multimodal CT may help identify patients who do not need thrombolysis, such as stroke mimics.

## Abstract

The role of CT angiography (CTA) and CT perfusion (CTP) in patient selection for thrombolysis <4.5 h after onset is unclear. Additional imaging may improve specificity of diagnosis by excluding stroke mimics or those without salvageable tissue, but may delay treatment.

In a multicentre prospective randomised trial, thrombolysis-eligible patients <4.5 h from symptom onset were randomised 1:1 to non-contrast CT (NCCT) or multimodal CT (NCCT + CTA + CTP). The primary endpoint was the proportion receiving thrombolysis. Secondary end-points were times to decision-making and treatment delivery, early neurological recovery, functional recovery at 3 months and incidence of symptomatic intracerebral haemorrhage (SICH).

Between March 2015 and May 2018, 271 patients were randomised, 134 to multimodal CT and 137 to NCCT. After initial NCCT, 114 had no contraindication to thrombolysis in the multimodal CT group and 108 in the NCCT group. Mean age was 67.5 years and median NIHSS score was 6 (interquartile range 3–12). Fewer patients assigned multimodal CT received thrombolysis (56/114, 49.1%) compared to NCCT (73/108, 67.6%, adjusted odds ratio (aOR) 0.46 (95% CI: 0.25–0.83), p = 0.0102). Times to treatment decision or thrombolytic administration, early neurological recovery and day 90 functional outcome did not differ significantly. SICH occurred in two patients, both assigned NCCT. Mortality was 6/114 (5.3%) in the multimodal CT group compared to 11/108 (10.2%; aOR 0.46 (95% CI: 0.16, 1.31), p = 0.147) in the NCCT group.

Despite fewer patients receiving thrombolysis after multimodal imaging, treatment decision times and clinical outcomes did not differ significantly. Multimodal CT may identify patients who do not require thrombolysis such as stroke mimics and non-disabling strokes.

Among acute stroke patients imaged <4.5 h from symptom onset, multimodal CT reduced use of thrombolysis. Treatment decision times and clinical outcomes did not differ between groups.

Graphical abstract