Article Impact Level: HIGH Data Quality: STRONG Summary of The Lancet Neurology, 24(6), 489–499. https://doi.org/10.1016/S1474-4422(25)00111-5 Dr. Luciano A. Sposato et al.
Points
- This prospective, randomized trial aimed to assess if extending CT angiography below the carina could improve the detection of cardioaortic thrombi in patients experiencing an acute ischemic stroke.
- The modified intention-to-treat analysis included 465 patients with ischemic stroke or transient ischemic attack who were randomly assigned to either the extended or standard CT angiography group.
- The extended CT angiography group showed a significantly higher detection rate of cardioaortic thrombi, at 8.8%, compared to 1.7% in the standard CT angiography group.
- Researchers found no statistically significant difference in the time to CT angiography completion, with a median difference of only one minute between the extended and standard imaging groups.
- The study concludes that this extended imaging technique is feasible during acute stroke workups, warranting further research on its impact on preventing recurrent strokes through earlier diagnosis.
Summary
This prospective, randomized trial evaluated whether extended CT angiography (eCTA), with imaging extended at least 6 cm below the carina, could increase the detection of cardioaortic thrombi in patients with acute ischemic stroke or transient ischemic attack compared to standard CT angiography (sCTA). The study enrolled 830 patients, with 465 ultimately included in the modified intention-to-treat analysis following exclusions for stroke mimics. The final cohort consisted of 226 patients in the eCTA group and 239 in the sCTA group, with a median age of 78.0 years (interquartile range, IQR, 69.0–84.0) and 51% female participants.
The primary efficacy outcome, detection of a cardioaortic thrombus, was significantly higher in the eCTA group. A thrombus was identified in 20 of 226 patients (8.8%) who received eCTA, compared to only 4 of 239 patients (1.7%) in the sCTA group. This represents a more than fivefold increase in detection, with an odds ratio of 5.70 (95% CI, 1.92–16.96; p = 0.002). The primary safety outcome, time to imaging completion, showed no significant difference between the groups, demonstrating the feasibility of the extended protocol in an acute setting.
The median time from code stroke activation to CT angiography completion was 21.0 minutes for the eCTA group and 20.0 minutes for the sCTA group, with a nonsignificant median difference of 1.0 minutes (p = 0.67). These findings suggest that performing eCTA during the initial stroke workup is a practical and effective method for substantially improving the diagnostic yield of cardioembolic sources. The researchers conclude that this enhanced detection, achieved without causing delays, warrants future studies to assess its impact on reducing recurrent stroke risk through earlier implementation of appropriate anticoagulation therapy.
Link to the article: https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(25)00111-5/abstract
References Sposato, L. A., Ayan, D., Ahmed, M., Fridman, S., Mandzia, J. L., Elrayes, M., Lodol, F., Khaw, A. V., Mai, L. M., Bogiatzi, C., Casserly, C., Fraser, J. A., Chan, R., Florendo Cumbermack, A., Markovic, N., Yu, Y., Debicki, D., Fleming, L., Beauchamp, B., … Bagur, R. (2025). Extended CT angiography versus standard CT angiography for the detection of cardioaortic thrombus in patients with ischaemic stroke and transient ischaemic attack (Daylight): A prospective, randomised, open-label, blinded end-point trial. The Lancet Neurology, 24(6), 489–499. https://doi.org/10.1016/S1474-4422(25)00111-5
