Abstract
Recurrent stroke is considered to increase the incidence of severe disability and death. For correct risk assessment and patient management it is essential to identify the origin of stroke at an early stage. Transthoracic echocardiography (TTE) is the initial standard of care for evaluating patients in whom a cardioembolic source of stroke (CES) is suspected but its diagnostic capability is limited. Transesophageal echocardiography (TEE) is considered as gold standard; however, this approach is time consuming, semi-invasive and not always feasible. We hypothesized that adding a delayed-phase cardiac computed tomography (cCT) to initial multimodal CT might represent a valid alternative to routine clinical echocardiographic work-up. Patients with suspected acute cardioembolic stroke verified by initial multimodal CT and subsequently examined with cCT were included. The cCT was evaluated for presence of major CES and compared to routine clinical echocardiographic work-up. In all, 102 patients with suspected acute CES underwent cCT. Among them 60 patients underwent routine work-up with echocardiography (50 TTE and only 10 TEE). By cCT 10/60 (16.7%) major CES were detected but only 4 (6.7%) were identified by echocardiography. All CES observed by echocardiography were also detected by cCT. In 8 of 36 patients in whom echocardiography was not performed cCT also revealed a major CES. These preliminary results show the potential diagnostic yield of delayed-phase cCT to detect major CES and therefore could accelerate decision-making to prevent recurrence stroke. To confirm these results larger studies with TEE as the reference standard and also compared to TTE would be necessary.
Highlights
In preparation for our study, we evaluated several published protocol variants, including non-electrocardiogram (ECG) gated cardiac CT as well as extending CTA gating up to diaphragm level according to the aforementioned literature [8]; using these protocols in our patients we observed more frequent limitations in terms of assessability of CES when non-ECG gated CTA was applied compared to our final protocol
The delayed and ECG-triggered cardiac CT in an acute stroke setting used in our study resulted in higher diagnostic yield and image quality with potential diagnostic benefit
We agree with the suggestions of Yeo et al that extended CTA might be sufficient in some cases; we are convinced considering our experience and several other studies [10, 12] that an ECG gated delayed phase cardiac CT has a superior efficiency in particular with respect to CES
Summary
In preparation for our study, we evaluated several published protocol variants, including non-electrocardiogram (ECG) gated cardiac CT as well as extending CTA gating up to diaphragm level according to the aforementioned literature [8]; using these protocols in our patients we observed more frequent limitations in terms of assessability of CES when non-ECG gated CTA was applied compared to our final protocol. 3 Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany left atrial appendage (LAA) and other important cardiac structures, including valves, due to pulsation artifacts.
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