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DAYLIGHT

Extended CT angiography versus standard CT angiography for the detection of cardioaortic thrombus in patients with ischaemic stroke and transient ischaemic attack (DAYLIGHT)

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Year of Publication: 2025

Authors: Luciano A Sposato, Diana Ayan, Mobeen Ahmed, ..., Rodrigo Bagur

Journal: The Lancet Neurology

Citation: Lancet Neurol. 2025;24:489–499

Link: https://www.thelancet.com/journals/laneu...0104-6/fulltext

PDF: https://www.researchgate.net/profile/Fas...saWNhdGlvbiJ9fQ

Clinical Question

Does extended head-to-heart CT angiography increase detection of cardioaortic thrombus in acute stroke or TIA without delaying treatment?

Bottom Line

Extended CT angiography significantly improves detection of cardioaortic thrombus without delaying stroke care or increasing adverse effects, suggesting a simple and feasible strategy to enhance early cardiac source detection.

        Major Points
        Randomized, blinded-endpoint trial comparing standard vs extended CT angiography in acute stroke/TIA
Detection of cardioaortic thrombus significantly higher in extended CT group (8.8% vs. 1.7%; OR 5.70, 95% CI 1.92–16.96, p=0.002)
No delay in imaging or acute treatments (median time 21 min vs 20 min, p=0.67)
Number needed to screen = 14 for detection of 1 thrombus
Additional radiation exposure was minimal (1.2 mSv more)
Extended CTA may allow early thrombus detection before it is dissolved by thrombolysis or anticoagulation

      

Design

Study Type: Randomized, open-label, blinded-endpoint trial

Randomization: 1

Blinding: Blinded outcome adjudication

Enrollment Period: July 17, 2023 – May 6, 2024

Follow-up Duration: ≥30 days

Centers: 1

Countries: Canada

Sample Size: 830

Analysis: Modified intention-to-treat; logistic regression with prespecified and post-hoc sensitivity analyses

Inclusion Criteria

Adults ≥18 years
Assessed during acute code stroke with suspected ischaemic stroke or TIA

Exclusion Criteria

Known allergy or safety concern with iodinated contrast (e.g., severe renal failure)
No intravenous access
Prior CT angiography before arrival
Hemorrhagic stroke on initial CT
Stroke deemed unlikely by treating neurologist

Baseline Characteristics

Characteristic	Control	Active
Age, median (IQR)	78.0 (69.5–84.0)	78.0 (68.2–86.0)
Sex - Female	54%	49%
Sex - Male	46%	51%
Hypertension	70%	69%
Diabetes	30%	32%
Dyslipidemia	52%	49%
Cancer	15%	19%
Chronic Kidney Disease	14%	9%
Heart Failure	10%	10%
Coronary Artery Disease	25%	25%
Previous Stroke	20%	20%
Any Atrial Fibrillation	40%	41%
Previously Known AF	20%	27%
New AF on ECG	8%	13%
New AF on Holter	16%	5%
New AF on Telemetry	17%	21%

Arms

Field	Extended CT Angiography	Control
Intervention	Non-ECG-gated CTA extended ≥6 cm below carina to image left atrial appendage and heart	Head and neck CTA to aortic arch (standard care)
Duration	Single diagnostic scan	Single diagnostic scan

Outcomes

Outcome	Type	Control	Intervention	HR / OR / RR	P-value
Detection of confirmed or highly suspected cardioaortic thrombus ≥30 days after qualifying event	Primary	1.7%	8.8%		0.002
Cardioaortic thrombus, vegetation, or tumour	Secondary	2.9%	9.7%	3.57	0.004
Any cardioembolic source (composite)	Secondary	30.5%	38.5%	1.42	0.07
De novo treatment initiated for detected embolic source	Secondary	13.4%	12.4%	0.91	0.75
Time to CTA Completion	Adverse	20 min	21 min		0.67
Radiation Exposure (mSv)	Adverse	15.0	16.1		0.0013
Contrast-Induced Nephropathy	Adverse	1	0

Subgroup Analysis

No significant interaction across subgroups including age, sex, AF status, or stroke severity

Criticisms

Single-centre design may limit external validity
Incomplete follow-up with advanced cardiac imaging
Possible underdetection or misclassification of thrombi
No evaluation of long-term clinical outcomes such as recurrence or mortality

Funding

Western University and the Kathleen and Dr Henry Barnett Chair in Stroke Research

Based on: DAYLIGHT (The Lancet Neurology, 2025)