UK Stroke Forum 2025 | The PRACTISE trial: CT perfusion and angiography versus CT alone in thrombolysis-eligible AIS

So the PRACTISE trial was undertaken to see if we could identify an appropriate strategy to identify patients suitable for thrombolysis and we randomized patients to non-contrast CT alone or in combination with CT perfusion and CTA. The trial was interesting because we started from the premise that we would find people uncertain about treatment and therefore more likely to treat when we were providing more evidence of vessel occlusion or perfusion defects. But we found interestingly the opposite. People were inclined to treat as the default and I think that represents a change in clinical behaviour over the time interval from when we conceived the trial to when it was actually undertaken. And when we provided more evidence, in particular of the absence of a vessel occlusion or perfusion defect, we saw a significant reduction in thrombolysis rates. Now you can interpret that in several ways. One of them might be that we are missing small strokes, which are not going to be detected in perfusion and therefore failing to treat some patients who might otherwise be eligible. But on the other hand, we may be diagnosing strokes more correctly. And we know there’s a real problem with stroke mimics appearing at a pretty high rate in some of the recent trials of thrombolysis and 1 in 13 of all patients receiving a thrombolytic drug in England and Wales in the recent audit. So we have some significant issues with diagnosis, particularly of these patients with minor symptoms. When you look at the outcome in the PRACTISE trial, despite the 20% reduction in thrombolysis rates, the outcomes in terms of disability were not different. So it is certainly conceivable that we are seeing evidence here that minor strokes perhaps do not require treatment. Stroke mimics certainly don’t require treatment. And perhaps there’s a better way of approaching the diagnostic pathways for these people with minor symptoms to ensure that we’re getting the right people treated.

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