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Zhang T, Zhou H, Yang J, Zhou Y, Chen Y, He Y, Xue R, Chen Z, Lou M, Yan S. Presence of Residual Cardiac Thrombus Predicts Poor Outcome in Cardioembolic Stroke After Reperfusion Therapy. J Am Heart Assoc 2024; 13:e032200. [PMID: 38390794 PMCID: PMC10944052 DOI: 10.1161/jaha.123.032200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 01/26/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND In patients with acute cardiogenic cerebral embolism, a residual thrombus may still be present in the cardiac cavity even after reperfusion therapy. We aimed to investigate the occurrence of a residual cardiac thrombus in cardioembolic stroke after reperfusion therapy and analyze its impact on clinical outcome. METHODS AND RESULTS We enrolled patients with cardioembolic stroke from our prospectively collected database who underwent 2-phase cardiac computed tomography within 7 days after reperfusion therapy. Residual cardiac thrombus was defined as a filling defect on both early- and late-phase images, whereas circulatory stasis was defined as a filling defect only on the early-phase images in the left atrial appendage. The primary outcome was a poor clinical outcome (modified Rankin Scale score, 3-6) at 90 days. The secondary outcome was a composite end point event (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke) at 90 days. A total of 303 patients were included, of whom 94 (31.0%) had a residual cardiac thrombus. Binary logistic regression analysis showed that the presence of a residual cardiac thrombus was associated with a poor clinical outcome (odds ratio, 1.951 [95% CI, 1.027-3.707]; P=0.041) but not circulatory stasis in the left atrial appendage (odds ratio, 1.096 [95% CI, 0.542-2.217]; P=0.798). Furthermore, there was no correlation between a residual cardiac thrombus and the composite end point event (30.0% versus 31.1%; P=1.000). CONCLUSIONS Residual cardiac thrombus occurs in approximately one-third of patients with cardioembolic stroke after reperfusion therapy and is often indicative of a poor clinical outcome.
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Affiliation(s)
- Tingxia Zhang
- Department of NeurologyThe 2nd Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Huan Zhou
- Department of NeurologyThe 2nd Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Jiansheng Yang
- Department of NeurologyThe 2nd Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Ying Zhou
- Department of NeurologyThe 2nd Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Yi Chen
- Department of NeurologyThe 2nd Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Yaode He
- Department of NeurologyThe 2nd Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Rui Xue
- Department of NeurologyThe 2nd Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Zhicai Chen
- Department of NeurologyThe 2nd Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Min Lou
- Department of NeurologyThe 2nd Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
| | - Shenqiang Yan
- Department of NeurologyThe 2nd Affiliated Hospital of Zhejiang University, School of MedicineHangzhouChina
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Khenkina N, Aimo A, Fabiani I, Masci PG, Sagris D, Williams SE, Mavraganis G, Chen HS, Wintermark M, Michel P, Ntaios G, Georgiopoulos G. Magnetic resonance imaging for diagnostic workup of embolic stroke of undetermined source: A systematic review. Int J Stroke 2024; 19:293-304. [PMID: 37435743 DOI: 10.1177/17474930231189946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) refers to ischemic stroke where the underlying cause of thromboembolism cannot be found despite the recommended diagnostic workup. Unidentified source of emboli hinders clinical decision-making and patient management with detrimental consequences on long-term prognosis. The rapid development and versatility of magnetic resonance imaging (MRI) make it an appealing addition to the diagnostic routine of patients with ESUS for the assessment of potential vascular and cardiac embolic sources. AIMS To review the use of MRI in the identification of cardiac and vascular embolic sources in ESUS and to assess the reclassification value of MRI examinations added to the conventional workup of ESUS. SUMMARY OF REVIEW We reviewed the use of cardiac and vascular MRI for the identification of a variety of embolic sources associated with ESUS, including atrial cardiomyopathy, left ventricular pathologies, and supracervical atherosclerosis in carotid and intracranial arteries and in distal thoracic aorta. The additional reclassification after MRI examinations added to the workup of patients with ESUS ranged from 6.1% to 82.3% and varied depending on the combination of imaging modalities. CONCLUSION MRI techniques allow us to identify additional cardiac and vascular embolic sources and may further decrease the prevalence of patients with the diagnosis of ESUS.
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Affiliation(s)
- Natallia Khenkina
- Postgraduate School of Diagnostic and Interventional Radiology, University of Milan, Milan, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Pier Giorgio Masci
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Dimitrios Sagris
- Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | | | - George Mavraganis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Max Wintermark
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Georgios Georgiopoulos
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
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3
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Barnea R, Agmon IN, Shafir G, Peretz S, Mendel R, Naftali J, Shiyovich A, Kornowski R, Auriel E, Hamdan A. Cardiac CT for intra-cardiac thrombus detection in embolic stroke of undetermined source (ESUS). Eur Stroke J 2022; 7:212-220. [PMID: 36082249 PMCID: PMC9446335 DOI: 10.1177/23969873221099692] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/22/2022] [Indexed: 10/17/2023] Open
Abstract
Introduction Embolic stroke of undetermined source (ESUS) is a common medical challenge regarding secondary prevention strategy. Cardiac imaging is the cornerstone of embolic stroke workup, in an effort to diagnose high risk cardio-embolic sources. Cardiac computed tomography angiography (CCTA) is an emerging imaging modality with high diagnostic performance for intra-cardiac thrombus detection. The yield of CCTA implementation in addition to standard care in ESUS workup is unknown. Thus, the aim of this study was to assess the utility of CCTA in detecting intra-cardiac thrombi in the routine ESUS workup. Patients and methods This is a retrospective observational analysis of ESUS cases managed in vascular neurology unit between 2019 and 2021. Within this ESUS registry, consecutive patients undergoing CCTA were included and carefully analyzed. Results During the study period 1066 Ischemic stroke (IS) cases were treated and evaluated. 266/1066 (25%) met ESUS criteria and 129/266 (48%) underwent CCTA. Intra-cardiac thrombus was detected by CCTA in 22/129 (17%; 95% CI, 11.5%-23.5%) patients: left ventricular thrombus (LVT) in 13 (10.1%) patients, left atrial appendage (LAA) thrombus in 8 (6.2%) patients, and left atrial (LA) thrombus in 1 (0.8%) patient. Only 5/22 (23%) of these thrombi were suspected, but could not be confirmed, in trans-thoracic echocardiogram (TTE). Among CCTA-undergoing patients, 27/129 (21%; 95% CI, 14%-28%) were found to have an indication (including pulmonary embolism) for commencing anticoagulation (AC) treatment, rather than anti-platelets. In favor of CCTA implementation, 22/266 (8.2%; 95% CI, 4.9%-11.5%) patients within the entire ESUS cohort were diagnosed with intra-cardiac thrombus, otherwise missed. Conclusion CCTA improves the detection of intra-cardiac thrombi in addition to standard care in ESUS patients. The implementation of CCTA in routine ESUS workup can change secondary prevention strategy in a considerable proportion of patients.
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Affiliation(s)
- Rani Barnea
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Inbar Nardi Agmon
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Gideon Shafir
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Shlomi Peretz
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Rom Mendel
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Jonathan Naftali
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Arthur Shiyovich
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Ran Kornowski
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Ashraf Hamdan
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
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Austein F, Eden M, Both M, Salehi Ravesh M, Jansen O, Langguth P. In Reply: Practicability and Diagnostic Yield of One-Stop Stroke CT with Delayed-Phase Cardiac CT in Detecting Major Cardioembolic Sources of Acute Ischemic Stroke. Clin Neuroradiol 2021; 31:923-924. [PMID: 34228139 PMCID: PMC8648679 DOI: 10.1007/s00062-021-01045-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Friederike Austein
- Department of Neuroradiological Intervention and Diagnostics, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
| | - Matthias Eden
- Department of Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Marcus Both
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Mona Salehi Ravesh
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Olav Jansen
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Patrick Langguth
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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