Abstract
Objectives
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.
Results
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).
Conclusions
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.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Stroke and Cerebrovascular DiseasesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- 12-Monats-Prävalenz von Schlaganfall oder chronischen Beschwerden infolge eines Schlaganfalls in Deutschland.J Health Monitoring. 2017; 2: 70-76https://doi.org/10.17886/RKI-GBE-2017-010
- Stroke incidence and survival in Ludwigshafen am Rhein, Germany: the Ludwigshafen Stroke Study (LuSSt).Stroke. 2010; 41: 1865-1870
- Secular trend in ischemic stroke subtypes and stroke risk factors.Stroke. 2014; 45: 3208-3213
- Twenty-year time trends in long-term case-fatality and recurrence rates after ischemic stroke stratified by etiology.Stroke. 2020; 51: 2778-2785
- Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation.Ann Thorac Surg. 1996; 61: 755-759
- Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation.Lancet Neurol. 2019; 18: 117-126
- Early recurrent embolism associated with nonvalvular atrial fibrillation: a retrospective study.Stroke. 1983; 14: 688-693
- Early and late mortality of spontaneous hemorrhagic transformation of ischemic stroke.J Stroke Cerebrovasc Dis. 2014; 23: 649-654
- 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
- Left atrial appendage thrombus and embolic stroke.Stroke. 2018; 49: e286-e289https://doi.org/10.1161/STROKEAHA.118.022674
- 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
- Safety of transesophageal echocardiography.J Am Soc Echocardiogr. 2010; 23: 1115-1127
- CT angiography vs echocardiography for detection of cardiac thrombi in ischemic stroke: a systematic review and meta-analysis.J Neurol. 2020; 267: 1793-1801
- The measurement of observer agreement for categorical data.Biometrics. 1977; 33: 159-174
- 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
- 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
- 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
- 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
- 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
- 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
- Cardioembolic stroke: dual-energy cardiac CT for differentiation of left atrial appendage thrombus and circulatory stasis.Radiology. 2012; 263: 688-695
- Cerebral Embolism Task Force.Arch Neurol. 1986; 43 (22): 71-84
- 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
- Anticoagulation type and early recurrence in cardioembolic stroke: the IAC Study.Stroke. 2020; 51: 2724-2732
- Left Atrial Appendage Thrombus Detected During Hyperacute Stroke Imaging Is Associated with Atrial Fibrillation.Stroke. 2020; 51: 3760-3764
- Cardiac imaging within emergency CT angiography for acute stroke can detect atrial clots.Front Neurol. 2019; 10: 349
- 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
- High rate of cardiac thrombus diagnosed by adding cardiac imaging in acute stroke computed tomography protocol.Int J Stroke. 2021; 16: 692-700
Article info
Publication history
Published online: December 13, 2022
Accepted:
December 7,
2022
Received in revised form:
November 1,
2022
Received:
July 24,
2022
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106936
Copyright
© 2022 Elsevier Inc. All rights reserved.
