Left atrial appendage thrombus in acute stroke: diagnostic accuracy of CT angiography compared to transesophageal echocardiography



      To evaluate the value of an extended emergency computed tomography angiography (CTA) including cardiac imaging in patients with acute ischemic stroke for the detection of left atrial appendage (LAA) thrombus compared to transesophageal echocardiography (TEE) as a reference standard.

      Materials and Methods

      We conducted a retrospective case-control study of patients with presumed acute ischemic stroke who had undergone non-ECG-gated CTA for the craniocervical vessels with an extended coverage including the heart in the context of emergency stroke evaluation and for whom TEE was available as part of the routine stroke diagnostic. We selected cases with evidence of LAA thrombus in TEE and controls without LAA thrombus in TEE in a 1:3 ratio. Two independent observers analyzed CTA images for presence of LAA thrombus and were blinded to the presence of thrombus in TEE.


      Twenty-two patients with LAA thrombus in TEE, and 66 patients without LAA thrombus in TEE were included. The detection of LAA thrombus using CTA showed a sensitivity of 63.6%, a specificity of 81.8%, a positive predictive value of 53.9% and a negative predicted value of 87.1%. Interobserver agreement was only moderate (Cohen´s κ = 0.43).


      An extended emergency CTA including cardiac imaging can be helpful in early risk stratification in patients with stroke of cardioembolic origin. However, our data show that a standard CTA of craniocervical vessels with extended coverage of the heart is of limited value when compared to TEE, the standard method of detecting LAA thrombi.


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        • Busch MA
        • Kuhnert R.
        12-Monats-Prävalenz von Schlaganfall oder chronischen Beschwerden infolge eines Schlaganfalls in Deutschland.
        J Health Monitoring. 2017; 2: 70-76
        • Palm F
        • Urbanek C
        • Rose S
        • et al.
        Stroke incidence and survival in Ludwigshafen am Rhein, Germany: the Ludwigshafen Stroke Study (LuSSt).
        Stroke. 2010; 41: 1865-1870
        • Bogiatzi C
        • Hackam DG
        • McLeod I
        • et al.
        Secular trend in ischemic stroke subtypes and stroke risk factors.
        Stroke. 2014; 45: 3208-3213
        • Rücker V
        • Heuschmann PU
        • O'Flaherty M
        • et al.
        Twenty-year time trends in long-term case-fatality and recurrence rates after ischemic stroke stratified by etiology.
        Stroke. 2020; 51: 2778-2785
        • Blackshear JL
        • Odell JA.
        Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation.
        Ann Thorac Surg. 1996; 61: 755-759
        • Seiffge DJ
        • Werring DJ
        • Paciaroni M
        • et al.
        Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation.
        Lancet Neurol. 2019; 18: 117-126
        • Hart RG
        • Coull BM
        • Hart D.
        Early recurrent embolism associated with nonvalvular atrial fibrillation: a retrospective study.
        Stroke. 1983; 14: 688-693
        • D'Amelio M
        • Terruso V
        • Famoso G
        • et al.
        Early and late mortality of spontaneous hemorrhagic transformation of ischemic stroke.
        J Stroke Cerebrovasc Dis. 2014; 23: 649-654
        • Paciaroni M
        • Agnelli G
        • Falocci N
        • et al.
        Prognostic value of trans-thoracic echocardiography in patients with acute stroke and atrial fibrillation: findings from the RAF study.
        J Neurol. 2016; 263: 231-237
        • Grory BM
        • Chang A
        • Atalay MK
        • et al.
        Left atrial appendage thrombus and embolic stroke.
        Stroke. 2018; 49: e286-e289
        • Romero J
        • Husain SA
        • Kelesidis I
        • et al.
        Detection of left atrial appendage thrombus by cardiac computed tomography in patients with atrial fibrillation: a meta-analysis.
        Circ Cardiovasc Imaging. 2013; 6: 185-194
        • Hilberath JN
        • Oakes DA
        • Shernan SK
        • et al.
        Safety of transesophageal echocardiography.
        J Am Soc Echocardiogr. 2010; 23: 1115-1127
        • Groeneveld NS
        • Guglielmi V
        • Leeflang MMG
        • et al.
        CT angiography vs echocardiography for detection of cardiac thrombi in ischemic stroke: a systematic review and meta-analysis.
        J Neurol. 2020; 267: 1793-1801
        • Landis JR
        • Koch GG.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Kapa S
        • Martinez MW
        • Williamson EE
        • et al.
        ECG-gated dual-source CT for detection of left atrial appendage thrombus in patients undergoing catheter ablation for atrial fibrillation.
        J Interv Card Electrophysiol. 2010; 29: 75-81
        • Martinez MW
        • Kirsch J
        • Williamson EE
        • et al.
        Utility of nongated multidetector computed tomography for detection of left atrial thrombus in patients undergoing catheter ablation of atrial fibrillation.
        JACC Cardiovasc Imaging. 2009; 2: 69-76
        • Feuchtner GM
        • Dichtl W
        • Bonatti JO
        • et al.
        Diagnostic accuracy of cardiac 64-slice computed tomography in detecting atrial thrombi. Comparative study with transesophageal echocardiography and cardiac surgery.
        Invest Radiol. 2008; 43: 794-801
        • Dorenkamp M
        • Sohns C
        • Vollmann D
        • et al.
        Detection of left atrial thrombus dur-ing routine diagnostic work-up prior to pulmonary vein isolation for atrial fibrillation: Role of transesophageal echocardiography and multidetector computed tomography.
        Int J Cardiol. 2013; 163: 26-33
        • Tang RB
        • Dong JZ
        • Zhang ZQ
        • et al.
        Comparison of contrast enhanced 64-slice computed tomography and transesophageal echocardiography in detection of left atrial thrombus in pa-tients with atrial fibrillation.
        J Interv Card Electrophysiol. 2008; 22: 199-203
        • Wagner M
        • Butler C
        • Rief M
        • et al.
        Comparison of non-gated vs. electrocardiogram-gated 64-detector-row computed tomography for integrated electroanatomic mapping in patients undergoing pulmonary vein isolation.
        Europace. 2010; 12: 1090-1097
        • Hur J
        • Kim YJ
        • Lee HJ
        • et al.
        Cardioembolic stroke: dual-energy cardiac CT for differentiation of left atrial appendage thrombus and circulatory stasis.
        Radiology. 2012; 263: 688-695
        • Cardiogenic brain embolism.
        Cerebral Embolism Task Force.
        Arch Neurol. 1986; 43 (22): 71-84
        • Paciarioni M
        • Agnelli G
        • Falocci N
        • et al.
        Early recurrence and cerebral bleeding in patients with acute ischemic stroke and atrial fibrillation: effect of anticoagulation and its timing: the RAF Study.
        Stroke. 2015; 46: 2175-2182
        • Yaghi S
        • Mistry E
        • Liberman AL
        • et al.
        Anticoagulation type and early recurrence in cardioembolic stroke: the IAC Study.
        Stroke. 2020; 51: 2724-2732
        • Senadeera SC
        • Palmer DG
        • Keenan R
        • et al.
        Left Atrial Appendage Thrombus Detected During Hyperacute Stroke Imaging Is Associated with Atrial Fibrillation.
        Stroke. 2020; 51: 3760-3764
        • Popkirov S
        • Schlegel U
        • Weber W
        • et al.
        Cardiac imaging within emergency CT angiography for acute stroke can detect atrial clots.
        Front Neurol. 2019; 10: 349
        • Guglielmi V
        • Planken RN
        • Mihl C
        • et al.
        Non-gated cardiac CT angiography for detection of cardio-aortic sources of embolism in the acute phase of ischaemic stroke.
        J Neurol Neurosurg Psychiatry. 2020; 91: 442-443
        • Bernard A
        • Leclercq T
        • Comby PO
        • et al.
        High rate of cardiac thrombus diagnosed by adding cardiac imaging in acute stroke computed tomography protocol.
        Int J Stroke. 2021; 16: 692-700