Abstract
INTRODUCTION: 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. PATIENTS AND METHODS: 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). RESULTS: 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. DISCUSSION: 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. CONCLUSION: 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.