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Updated: Jul 9, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Role of cardiac computed tomography in hyperacute stroke assessment
Shinya Tomari1, Beng Lim Alvin Chew2, Barry Soans3
1Hunter Medical Research Institute, Newcastle, Australia.
Insights
A National Institutes of Health Stroke Scale (NIHSS) score of 4 or higher identifies patients who may benefit from cardiac CT for cardioembolic stroke detection. This threshold helps optimize diagnostic yield and reduce unnecessary radiation exposure in hyperacute stroke cases.
Area of Science:
- Cardiology
- Neurology
- Radiology
Background:
- Cardiac CT in hyperacute stroke imaging can identify cardioembolic sources.
- The influence of stroke severity on intracardiac thrombus rates is unclear.
- Investigating a National Institutes of Health Stroke Scale (NIHSS) threshold to determine the necessity of acute cardiac CT is crucial.
Purpose of the Study:
- To determine if a specific NIHSS score threshold can identify patients unlikely to have intracardiac thrombus.
- To optimize the use of cardiac CT in hyperacute stroke evaluation.
- To reduce unnecessary radiation exposure in stroke patients.
Main Methods:
- Prospective recruitment of consecutive patients with suspected stroke undergoing multimodal brain imaging and concurrent non-gated cardiac CT.
- Utilizing receiver operating characteristic (ROC) analysis to evaluate the NIHSS and intracardiac thrombus detection on hyperacute cardiac CT.
- Data collection occurred from December 1, 2020, to November 30, 2021.
Main Results:
- 314 patients were assessed; 205 had ischemic stroke, 21 had TIA, and 88 had stroke-mimic syndromes.
- Cardiac CT identified intracardiac thrombus in 4.5% of etiology-confirmed stroke and 2.7% of cryptogenic stroke cases.
- An NIHSS score of ≥4 was the threshold below which hyperacute cardiac CT was not justified (sensitivity 100%, specificity 38%, NPV 100%).
Conclusions:
- A cutoff NIHSS score of ≥4 may effectively stratify patients for cardiac CT in hyperacute stroke.
- This approach can optimize the diagnostic yield of cardiac CT.
- Reducing radiation exposure in selected stroke patients is a key benefit.
Background:
Incorporating cardiac CT with hyperacute stroke imaging may increase the yield for cardioembolic sources. It is not clarified whether stroke severity influences on rates of intracardiac thrombus. We aimed to investigate a National Institutes of Health Stroke Scale (NIHSS) threshold below which acute cardiac CT was unnecessary.
Methods:
Consecutive patients with suspected stroke who underwent multimodal brain imaging and concurrent non-gated cardiac CT with delayed timing were prospectively recruited from 1st December 2020 to 30th November 2021. We performed receiver operating characteristics analysis of the NIHSS and intracardiac thrombus on hyperacute cardiac CT.
Results:
A total of 314 patients were assessed (median age 69 years, 61% male). Final diagnoses were ischemic stroke (n=205; 132 etiology-confirmed stroke, independent of cardiac CT and 73 cryptogenic), transient ischemic attack (TIA) (n=21) and stroke-mimic syndromes (n=88). The total yield of cardiac CT was 8 intracardiac thrombus and 1 dissection. Cardiac CT identified an intracardiac thrombus in 6 (4.5%) with etiology-confirmed stroke, 2 (2.7%) with cryptogenic stroke, and none in patients with TIA or stroke-mimic. All of those with intracardiac thrombus had NIHSS ≥4 and this was the threshold below which hyperacute cardiac CT was not justified (sensitivity 100%, specificity 38%, positive predictive value 4.0%, negative predictive value 100%).
Conclusions:
A cutoff NIHSS ≥4 may be useful to stratify patients for cardiac CT in the hyperacute stroke setting to optimize its diagnostic yield and reduce additional radiation exposure.
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