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Updated: Oct 25, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Feasibility of the Big 5-Jena eCS Protocol : First Experience Implementing a New Extended CT Protocol in the Initial
Moisés F Molina-Fuentes1,2,3, Rotraud Neumann4,5, Wilhelm Behringer6
1Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany. moisesm@uninorte.edu.co.
Insights
The Big 5-Jena extended cardio-stroke protocol is a feasible new tool for detecting thoracic cardiovascular thrombi in acute stroke patients. This imaging protocol shows promise in identifying clots missed by traditional echocardiography, with acceptable radiation exposure.
Area of Science:
- Cardiology
- Neurology
- Radiology
Background:
- Standard acute ischemic stroke diagnostics often miss cardiogenic and aortic embolism sources.
- Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are typically used for later evaluation of these causes.
- There is a need for earlier and more comprehensive diagnostic tools in acute stroke management.
Purpose of the Study:
- To evaluate the feasibility of a novel extended cardio-stroke protocol (Big 5-Jena eCS protocol) for detecting thoracic cardiovascular thrombi.
- To assess the diagnostic capabilities of this new protocol in acute stroke patients.
- To compare the protocol's performance against traditional diagnostic methods.
Main Methods:
- Retrospective analysis of tomography scans from Jena University Hospital.
- Inclusion of 67 patients for feasibility analysis based on three outcomes.
- Evaluation of thrombi detection in various thoracic locations.
Main Results:
- The Big 5-Jena eCS protocol successfully detected thoracic cardiovascular thrombi in 20 patients across multiple locations (aorta, valves, atria, ventricles, pulmonary arteries).
- Implementation did not significantly increase radiation exposure compared to standard protocols.
- Seven cases of thrombi were identified by the new protocol but missed by echocardiography.
Conclusions:
- The Big 5-Jena eCS protocol is a feasible, time-efficient imaging tool for acute stroke patients, providing assessable images with acceptable radiation levels.
- The protocol demonstrated the ability to detect thrombi not identified by TTE or TEE, suggesting potential for improved diagnosis.
- Further prospective studies and clinical trials are necessary to confirm diagnostic accuracy and clinical impact compared to echocardiography.
Purpose:
The most common protocols in the initial diagnostic of acute ischemic stroke do not assess cardiogenic or aortic causes of embolism. These are usually evaluated later by transthoracic (TTE) or transesophageal (TEE) echocardiography. This study aimed to evaluate the feasibility of a diagnostic tool for thoracic cardiovascular thrombi according to the first experience with a new extended cardio-stroke protocol (Big 5-Jena eCS protocol) in acute stroke patients.
Methods:
Retrospective analyses of the tomography scans database of the Jena University Hospital were performed. We included a total of 67 patients in the feasibility analyses, based on the evaluation of three outcomes.
Results:
Primary outcome: the Big 5-Jena eCS protocol was able to detect thoracic cardiovascular thrombi in a total of 20 patients in different locations including the arch of the aorta, the aortic valve, the left atrium, the left atrial appendage, the left ventricle, and the pulmonary arteries. Secondary outcome: implementating the protocol did not result in a significant elevation of the radiation exposure compared to traditional protocols. Tertiary outcome: the new protocol identified seven cases that were considered negative by echocardiography.
Conclusion:
The implementation of an extended cardio-stroke protocol is feasible, no significantly time-consuming, acquiring assessable imaging, and maintaining radiation exposure acceptable. The Big 5-Jena eCS protocol was also able to detect some thrombi not reported by TTE or TEE; however, due to our data's explorative character, a conclusive comparison with cardiac ultrasound is not possible. A prospective pilot study and clinical trials should be conducted to assess the diagnostic accuracy of this protocol compared to echocardiography and determine the potential impact on diagnostic and treatment decisions.
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