Practicability and Diagnostic Yield of One-Stop Stroke CT with Delayed-Phase Cardiac CT in Detecting Major Cardioembolic Sources of Acute Ischemic Stroke

Friederike Austein,Jakob Engel,Tim-Christian Piesch,Mona Salehi Ravesh,Matthias Eden,Patrick Langguth,Olav Jansen,Annett Lebenatus,Marcus Both,Naomi Larsen,Johannes Meyne

doi:10.1007/s00062-021-01003-7

Abstract

PurposeRecurrent 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.Material and MethodsPatients 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.ResultsIn 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.ConclusionThese 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

Patients presenting at the emergency department (ED) with symptoms of acute ischemic stroke (AIS) due to large-vessel occlusion are typically examined with multimodal computed tomography (CT), which includes noncontrast-enhanced CT, CT angiography (CTA), and CT perfusion (CTP) [1]
Our results demonstrate that the cardiac CT (cCT) protocol provides an advantage in the early diagnosis of major cardioembolic stroke (CES) in terms of time to diagnosis and diagnostic accuracy
We looked at patients with known large vessel occlusion suspected of being the source of cardioembolic stroke, which increased the pretest probability for cardiac thrombi; the greatest clinical benefit of this method would be expected in patients with cryptogenic stroke, where detecting a cardiac thrombus has profound implications for acute treatment and secondary prevention

Summary

Introduction

Patients presenting at the emergency department (ED) with symptoms of acute ischemic stroke (AIS) due to large-vessel occlusion are typically examined with multimodal computed tomography (CT), which includes noncontrast-enhanced CT, CT angiography (CTA), and CT perfusion (CTP) [1]. Echocardiographic evaluation is recommended in the acute phase of stroke mainly for etiological and therapeutic purposes and for assessing cardiovascular comorbidities; facing an increasing incidence of stroke, concerning access to transesophageal echocardiography (TEE) owing to organizational strains, there are often delays in completing the examinations during the hospital stay, which increases the length of hospitalization [3, 4] and contributes to an increase in both direct and indirect healthcare costs. That adding a delayed-phase cardiac CT (cCT) to the initial multimodal CT might represent a valid alternative to routine clinical echocardiographic (Transthoracic Echocardiography [TTE] or TEE) work-up

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Results

Discussion

Conclusion