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Published on: June 11, 2019
Cardiac CT for intra-cardiac thrombus detection in embolic stroke of undetermined source (ESUS)
Rani Barnea1,2, Inbar Nardi Agmon2,3, Gideon Shafir2,4
1Department of Neurology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.
Insights
Cardiac computed tomography angiography (CCTA) significantly improves the detection of intra-cardiac thrombi in patients with embolic stroke of undetermined source (ESUS). This advanced imaging can alter secondary prevention strategies for a notable number of ESUS patients.
Area of Science:
- Cardiology
- Neurology
- Radiology
Background:
- Embolic stroke of undetermined source (ESUS) presents a significant challenge for secondary prevention.
- Cardiac imaging is crucial for identifying high-risk cardio-embolic sources in ESUS.
- Cardiac computed tomography angiography (CCTA) shows promise for detecting intra-cardiac thrombi.
Purpose of the Study:
- To evaluate the diagnostic utility of CCTA in detecting intra-cardiac thrombi within the standard ESUS workup.
- To determine if CCTA provides additional diagnostic yield beyond conventional methods for ESUS patients.
Main Methods:
- Retrospective observational analysis of ESUS cases from 2019-2021.
- Inclusion of consecutive ESUS patients who underwent CCTA.
- Analysis of CCTA findings for intra-cardiac thrombi and comparison with standard care.
Main Results:
- CCTA detected intra-cardiac thrombi in 17% of ESUS patients (22/129), including left ventricular and left atrial appendage thrombi.
- Trans-thoracic echocardiogram (TTE) only suspected 23% of these thrombi.
- CCTA identified an additional 8.2% of ESUS patients with intra-cardiac thrombi missed by standard workup, potentially altering treatment from anti-platelets to anticoagulation.
Conclusions:
- CCTA enhances the detection of intra-cardiac thrombi in ESUS patients compared to standard care.
- Implementing CCTA in routine ESUS workup can significantly change secondary prevention strategies for a considerable number of patients.
Introduction:
Embolic stroke of undetermined source (ESUS) is a common medical challenge regarding secondary prevention strategy. Cardiac imaging is the cornerstone of embolic stroke workup, in an effort to diagnose high risk cardio-embolic sources. Cardiac computed tomography angiography (CCTA) is an emerging imaging modality with high diagnostic performance for intra-cardiac thrombus detection. The yield of CCTA implementation in addition to standard care in ESUS workup is unknown. Thus, the aim of this study was to assess the utility of CCTA in detecting intra-cardiac thrombi in the routine ESUS workup.
Patients And Methods:
This is a retrospective observational analysis of ESUS cases managed in vascular neurology unit between 2019 and 2021. Within this ESUS registry, consecutive patients undergoing CCTA were included and carefully analyzed.
Results:
During the study period 1066 Ischemic stroke (IS) cases were treated and evaluated. 266/1066 (25%) met ESUS criteria and 129/266 (48%) underwent CCTA. Intra-cardiac thrombus was detected by CCTA in 22/129 (17%; 95% CI, 11.5%-23.5%) patients: left ventricular thrombus (LVT) in 13 (10.1%) patients, left atrial appendage (LAA) thrombus in 8 (6.2%) patients, and left atrial (LA) thrombus in 1 (0.8%) patient. Only 5/22 (23%) of these thrombi were suspected, but could not be confirmed, in trans-thoracic echocardiogram (TTE). Among CCTA-undergoing patients, 27/129 (21%; 95% CI, 14%-28%) were found to have an indication (including pulmonary embolism) for commencing anticoagulation (AC) treatment, rather than anti-platelets. In favor of CCTA implementation, 22/266 (8.2%; 95% CI, 4.9%-11.5%) patients within the entire ESUS cohort were diagnosed with intra-cardiac thrombus, otherwise missed.
Conclusion:
CCTA improves the detection of intra-cardiac thrombi in addition to standard care in ESUS patients. The implementation of CCTA in routine ESUS workup can change secondary prevention strategy in a considerable proportion of patients.
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