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Cardiac CT vs Echocardiography for Intracardiac Thrombus Detection in Ischemic Stroke: A Systematic Review and
Sherief Ghozy1, Michael Liu1, Hassan Kobeissi1
1From the Departments of Radiology (S.G., H.K., A.M., M.A., D.F.K., R.K.), Neurologic Surgery (S.G., R.K.), and Neurology (M.L., A.A.R., D.N.), Mayo Clinic, Rochester, MN; Evidence-based Practice Center (A.S.A.), Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN; Neuroendovascular Program (A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Neurovascular Centre, Divisions of Therapeutic Neuroradiology & Neurosurgery (A.A.D.), St. Michael's Hospital, University of Toronto, ON, Canada.
Insights
Cardiac CT (CCT) shows high accuracy in detecting intracardiac thrombus, a key cause of ischemic stroke, compared to echocardiography. This imaging technique offers a promising alternative for stroke diagnosis and prevention strategies.
Area of Science:
- Cardiovascular Imaging
- Neurology
- Radiology
Background:
- Ischemic stroke is a major cause of death, requiring understanding of its mechanisms for prevention.
- Transesophageal echocardiography (TEE) is the gold standard for detecting cardiac sources of stroke, such as left atrial thrombus.
- TEE's invasiveness and limitations necessitate exploring alternative imaging modalities like cardiac CT (CCT).
Purpose of the Study:
- To systematically review and meta-analyze the diagnostic performance of CCT in detecting intracardiac thrombus.
- To compare the efficacy of CCT against echocardiography for identifying cardiac sources of stroke.
Main Methods:
- Systematic literature review and random-effects meta-analysis of 43 studies involving 9,552 patients.
- Searched 4 databases up to September 8, 2023, using terms related to echocardiography, CT, stroke, and cryptogenic sources.
- Assessed risk of bias using the QUADAS-2 tool and calculated diagnostic metrics including sensitivity and specificity.
Main Results:
- CCT demonstrated high diagnostic performance with an overall sensitivity of 98.38% and specificity of 96.0% for intracardiac thrombus detection.
- Delayed-phase, electrocardiogram-gated CCT achieved 100% sensitivity, while early-phase, non-gated CCT showed 94.31% sensitivity.
- The diagnostic odds ratio was 98.59, indicating strong discriminative ability, though heterogeneity was noted in specificity and diagnostic odds ratio.
Conclusions:
- CCT exhibits high sensitivity and specificity for detecting intracardiac thrombus, serving as a viable alternative to echocardiography.
- Limitations include the absence of randomized controlled trials and the exclusion of other cardioembolic sources from the analysis.
- Further large-scale studies are recommended to validate CCT's role in identifying intracardiac thrombus and other cardioembolic stroke sources.
Background And Objectives:
Ischemic stroke, a leading cause of mortality, necessitates understanding its mechanism for effective prevention. Echocardiography, especially transesophageal echocardiography (TEE), is the gold standard for detection of cardiac sources of stroke including left atrial thrombus, although its invasiveness, operator skill dependence, and limited availability in some centers prompt exploration of alternatives, such as cardiac CT (CCT). We conducted a systematic review and meta-analysis assessing the ability of CCT in the detection of intracardiac thrombus compared with echocardiography.
Methods:
We searched 4 databases up through September 8, 2023. Major search terms included a combination of the terms "echocardiograph," "CT," "TEE," "imaging," "stroke," "undetermined," and "cryptogenic." The current systematic literature review of the English language literature was reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. We assessed risk of bias using the QUADAS-2 tool and used random-effects meta-analysis to calculate different diagnostic metrics.
Results:
The meta-analysis investigating CCT vs echocardiography for intracardiac thrombus detection yielded a total of 43 studies of 9,552 patients. Risk-of-bias assessment revealed a predominantly low risk of bias in the flow and timing, index test, and patient selection domains and a predominantly unclear risk of bias in the reference standard domain. The analysis revealed an overall sensitivity of 98.38% (95% CI 89.2-99.78) and specificity of 96.0% (95% CI 92.55-97.88). Subgroup analyses demonstrated that delayed-phase, electrocardiogram-gated CCT had the highest sensitivity (100%; 95% CI 0-100) while early-phase, nongated CCT exhibited a sensitivity of 94.31% (95% CI 28.58-99.85). The diagnostic odds ratio was 98.59 (95% CI 44.05-220.69). Heterogeneity was observed, particularly in specificity and diagnostic odds ratio estimates.
Discussion:
CCT demonstrates high sensitivity, specificity, and diagnostic odds ratios in detecting intracardiac thrombus compared with traditional echocardiography. Limitations include the lack of randomized controlled studies, and other cardioembolic sources of stroke such as valvular disease, cardiac function, and aortic arch disease were not examined in our analysis. Large-scale studies are warranted to further evaluate CCT as a promising alternative for identifying intracardiac thrombus and other sources of cardioembolic stroke.
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