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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Detection of Cardioembolic Sources With Nongated Cardiac Computed Tomography Angiography in Acute Stroke: Results
Frans Kauw1,2, Birgitta K Velthuis1, Richard A P Takx1
1Department of Radiology (F.K., B.K.V., R.A.P.T., F.v.O., A.B., E.B., H.W.A.M.d.J., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands.
Insights
Detecting cardiac thrombi with cardiac computed tomography angiography (CTA) in acute ischemic stroke patients improves cardioembolic source identification. Spectral imaging enhances detection of left atrial appendage thrombi, aiding secondary prevention strategies.
Area of Science:
- Cardiology
- Neurology
- Radiology
Background:
- Identifying cardioembolic sources is crucial for secondary stroke prevention strategies.
- Acute ischemic stroke (AIS) patients require prompt etiological diagnosis.
- Cardiac computed tomography angiography (CTA) is increasingly used in stroke evaluation.
Purpose of the Study:
- To evaluate the diagnostic yield of non-gated cardiac CTA in detecting cardioembolic sources in AIS patients.
- To assess the added value of spectral imaging for thrombus characterization.
- To determine the impact of detected cardiac thrombi on the likelihood of cardioembolic stroke.
Main Methods:
- Prospective investigation of AIS patients undergoing non-gated head-to-heart CTA.
- Cardiac thrombus detection and characterization using conventional CTA and spectral iodine maps.
- Expert panel assessment of cardioembolic source likelihood based on CTA findings.
- Comparison of stroke severity, clot burden, and treatment between patients with and without cardiac thrombi.
Main Results:
- Cardiac thrombi were identified in 12% of patients (35% left atrial appendage, 14% left ventricle).
- Patients with cardiac thrombi had more severe strokes and higher clot burden.
- Spectral iodine maps improved diagnostic certainty for left atrial appendage thrombi compared to conventional CTA.
- Presence of cardiac thrombus significantly increased the likelihood of a cardioembolic source.
Conclusions:
- Extending stroke CTA to include the heart improves detection of cardiac thrombi in acute ischemic stroke.
- Spectral imaging offers additional value for left atrial appendage thrombus detection.
- Cardiac CTA is a valuable tool for identifying cardioembolic sources and guiding secondary prevention.
Background:
Identifying cardioembolic sources in patients with acute ischemic stroke is important for the choice of secondary prevention strategies. We prospectively investigated the yield of admission (spectral) nongated cardiac computed tomography angiography (CTA) to detect cardioembolic sources in stroke.
Methods:
Participants of the ENCLOSE study (Improved Prediction of Recurrent Stroke and Detection of Small Volume Stroke) with transient ischemic attack or acute ischemic stroke with assessable nongated head-to-heart CTA at the University Medical Center Utrecht were included between June 2017 and March 2022. The presence of cardiac thrombus on cardiac CTA was based on a Likert scale and dichotomized into certainly or probably absent versus possibly, probably, or certainly present. The diagnostic certainty of cardiac thrombus was evaluated again on spectral computed tomography reconstructions. The likelihood of a cardioembolic source was determined post hoc by an expert panel in patients with cardiac thrombus on CTA. Parametric and nonparametric tests were used to compare the outcome groups.
Results:
Forty four (12%) of 370 included patients had a cardiac thrombus on admission CTA: 35 (9%) in the left atrial appendage and 14 (4%) in the left ventricle. Patients with cardiac thrombus had more severe strokes (median National Institutes of Health Stroke Scale score, 10 versus 4; P=0.006), had higher clot burden (median clot burden score, 9 versus 10; P=0.004), and underwent endovascular treatment more often (43% versus 20%; P<0.001) than patients without cardiac thrombus. Left atrial appendage thrombus was present in 28% and 6% of the patients with and without atrial fibrillation, respectively (P<0.001). The diagnostic certainty for left atrial appendage thrombus was higher for spectral iodine maps compared with the conventional CTA (P<0.001). The presence of cardiac thrombus on CTA increased the likelihood of a cardioembolic source according to the expert panel (P<0.001).
Conclusions:
Extending the stroke CTA to cover the heart increases the chance of detecting cardiac thrombi and helps to identify cardioembolic sources in the acute stage of ischemic stroke with more certainty. Spectral iodine maps provide additional value for detecting left atrial appendage thrombus.
Registration:
URL: https://www.
Clinicaltrials:
gov; Unique identifier: NCT04019483.
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