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Philippe D, Bernard A, Ricolfi F, Béjot Y, Duloquin G, Comby PO, Guenancia C. Prevalence of major embolic findings and incidental findings on early cardiac CT in patients with suspected ischemic stroke. Diagn Interv Imaging 2024:S2211-5684(24)00047-0. [PMID: 38431431 DOI: 10.1016/j.diii.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE The purpose of this study was to assess the type and prevalence of stroke and non-stroke-related findings diagnosed on early cardiac computed tomography (CT) in patients with suspected stroke. The secondary objective was to assess the clinical consequences on the management of patients with non-stroke-related conditions identified by early cardiac CT. MATERIALS AND METHODS This single-center, retrospective, observational study included 1111 consecutive patients with suspected ischemic stroke between November 2018 and March 2020 who underwent cardiac CT examination in addition to the usual brain CT protocol (i.e., non-enhanced brain CT, perfusion brain CT when needed, aortic arch and supra-aortic CT angiography, and post contrast brain CT). There were 562 women and 549 men with a median age of 74 years (range: 60-85 years). Of these, 415 (415/1111; 37.4%) patients had ischemic stroke and 692 (692/1111; 62.3%) had no stroke. Cardiac CT examinations were retrospectively reviewed for cardiac CT findings at high embolic risk and clinically significant extracardiac incidental findings. RESULTS Among 1111 included patients, 89 (89/1111; 8.0%) had a stroke-related condition identified on early cardiac CT. This was significantly more frequent in patients with ischemic stroke (66/415; 15.9%) by comparison with those without ischemic stroke (23/696; 3.3%) (P < 0.001), with 41 patients (41/415; 9.9%) diagnosed with left atrial thrombus. Cardiac CT revealed a clinically significant non-stroke-related finding in 173 patients (173/1111; 15.6%), including 17 pulmonary embolisms (1.5%), seven suspicious pulmonary lesions (0.6%), and three breast lesions suspected to be malignant (0.3%). Twenty out of 173 patients (20/173; 11.5%) with incidental findings on early cardiac CT had a change in their management. CONCLUSION This study shows that adding early cardiac CT to brain CT during the acute phase of an ischemic stroke leads to a higher rate of etiological diagnoses and highlights the major interest of looking at the bigger picture.
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Affiliation(s)
- Diane Philippe
- Department of Radiology, University Hospital, 21709 Dijon, France
| | | | - Frédéric Ricolfi
- Department of Radiology, University Hospital, 21709 Dijon, France
| | - Yannick Béjot
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Gauthier Duloquin
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Pierre-Olivier Comby
- Department of Radiology, University Hospital, 21709 Dijon, France; Department of Neurology, University Hospital, 21709 Dijon, France
| | - Charles Guenancia
- PEC2 EA7460, Université de Bourgogne et de Franche-Comté, 21709 Dijon, France; Department of Cardiology, University Hospital, 21709 Dijon, France.
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2
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Kotadia ID, O'Dowling R, Aboagye A, Crawley RJ, Bodagh N, Gharaviri A, O'Hare D, Solis‐Lemus JA, Roney CH, Sim I, Ramsey D, Newby D, Chiribiri A, Plein S, Sztriha L, Scott P, Masci P, Harrison J, Williams MC, Birns J, Somerville P, Bhalla A, Niederer S, O'Neill M, Williams SE. High Prevalence of New Clinically Significant Findings in Patients With Embolic Stroke of Unknown Source Evaluated by Cardiac Magnetic Resonance Imaging. J Am Heart Assoc 2024; 13:e031489. [PMID: 38240222 PMCID: PMC11056130 DOI: 10.1161/jaha.123.031489] [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: 10/13/2023] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Embolic stroke of unknown source (ESUS) accounts for 1 in 6 ischemic strokes. Current guidelines do not recommend routine cardiac magnetic resonance (CMR) imaging in ESUS, and beyond the identification of cardioembolic sources, there are no data assessing new clinical findings from CMR in ESUS. This study aimed to assess the prevalence of new cardiac and noncardiac findings and to determine their impact on clinical care in patients with ESUS. METHODS AND RESULTS In this prospective, multicenter, observational study, CMR imaging was performed within 3 months of ESUS. All scans were reported according to standard clinical practice. A new clinical finding was defined as one not previously identified through prior clinical evaluation. A clinically significant finding was defined as one resulting in further investigation, follow-up, or treatment. A change in patient care was defined as initiation of medical, interventional, surgical, or palliative care. From 102 patients recruited, 96 underwent CMR imaging. One or more new clinical findings were observed in 59 patients (61%). New findings were clinically significant in 48 (81%) of these patients. Of 40 patients with a new clinically significant cardiac finding, 21 (53%) experienced a change in care (medical therapy, n=15; interventional/surgical procedure, n=6). In 12 patients with a new clinically significant extracardiac finding, 6 (50%) experienced a change in care (medical therapy, n=4; palliative care, n=2). CONCLUSIONS CMR imaging identifies new clinically significant cardiac and noncardiac findings in half of patients with recent ESUS. Advanced cardiovascular screening should be considered in patients with ESUS. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04555538.
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Affiliation(s)
- Irum D. Kotadia
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Robert O'Dowling
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Akosua Aboagye
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Richard J. Crawley
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Neil Bodagh
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Ali Gharaviri
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
| | - Daniel O'Hare
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Jose Alonso Solis‐Lemus
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Caroline H. Roney
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Iain Sim
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | | | - David Newby
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Sven Plein
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | | | - Paul Scott
- King’s College HospitalLondonUnited Kingdom
| | - Pier‐Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | | | - Michelle C. Williams
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
| | - Jonathan Birns
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Peter Somerville
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Ajay Bhalla
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
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3
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Hull R, Carman N, Wilson A, Moulton M, Jordan MC, Stephens BD, Bush K. A Multidisciplinary Algorithm for the Evaluation of Acute Neurologic Deficits Improves Management of Cryptogenic Stroke or Transient Ischemic Attack. Cureus 2023; 15:e42728. [PMID: 37654966 PMCID: PMC10466960 DOI: 10.7759/cureus.42728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/02/2023] Open
Abstract
The appropriate diagnosis and management of cryptogenic stroke and transient ischemic attack (TIA) is challenging and requires multidisciplinary involvement. Joint societal guidelines exist to guide the comprehensive evaluation of these entities. This study aimed to implement a standardized multidisciplinary diagnostic algorithm for cryptogenic stroke/TIA. We performed a retrospective analysis of patients admitted to the largest regional military healthcare center with stroke or TIA considered to be cryptogenic at the time of discharge. We abstracted baseline demographics and rates of extra- and intracranial imaging, transthoracic and transesophageal echocardiography, and event monitor orders at the time of discharge. The incidence of event monitor results at 30 days and six months were included. A diagnostic algorithm for evaluation of cryptogenic stroke/TIA was created and disseminated hospital-wide using increased compliance with neuroimaging, echocardiography, and cardiac rhythm monitoring as primary endpoints for our intervention. Post-intervention data abstraction revealed similar rates of extra- and intracranial imaging, but significantly greater rates of transthoracic echocardiography (70% vs. 87%, p 0.0073), inclusion of agitated saline study (41% vs. 65%, p 0.0024), and event monitors ordered at discharge (18% vs. 35%, p 0.0045). At six months there was a higher rate of event monitors obtained (24% vs. 45%, p 0.001). Our study showed implementation of an evidence-based diagnostic algorithm for evaluation of cryptogenic stroke/TIA increases appropriate use of echocardiography and event monitoring.
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Affiliation(s)
- Robert Hull
- Cardiology, Brooke Army Medical Center, Fort Sam Houston, USA
| | | | - Andrew Wilson
- Cardiology, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Michael Moulton
- Cardiology, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Morgan C Jordan
- Neurology, Brooke Army Medical Center, Fort Sam Houston, USA
| | | | - Kelvin Bush
- Cardiology, Brooke Army Medical Center, Fort Sam Houston, USA
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4
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Rinkel LA, Bouma BJ, Boekholdt SM, Beemsterboer CFP, Lobé NHJ, Beenen LFM, Marquering HA, Majoie CBLM, Roos YBWEM, van Randen A, Planken RN, Coutinho JM. Detection of patent foramen ovale in patients with ischemic stroke on prospective ECG-gated cardiac CT compared to transthoracic echocardiography. J Neurol 2023:10.1007/s00415-023-11688-0. [PMID: 37027020 DOI: 10.1007/s00415-023-11688-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/23/2023] [Accepted: 03/25/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Cardiac CT acquired during the acute stroke imaging protocol is an emerging alternative to transthoracic echocardiography (TTE) to screen for sources of cardioembolism. Currently, its diagnostic accuracy to detect patent foramen ovale (PFO) is unclear. METHODS This was a substudy of Mind the Heart, a prospective cohort in which consecutive adult patients with acute ischemic stroke underwent prospective ECG-gated cardiac CT during the initial stroke imaging protocol. Patients also underwent TTE. We included patients < 60 years who underwent TTE with agitated saline contrast (cTTE) and assessed sensitivity, specificity, negative and positive predictive value of cardiac CT for the detection of PFO using cTTE as the reference standard. RESULTS Of 452 patients in Mind the Heart, 92 were younger than 60 years. Of these, 59 (64%) patients underwent both cardiac CT and cTTE and were included. Median age was 54 (IQR 49-57) years and 41/59 (70%) were male. Cardiac CT detected a PFO in 5/59 (8%) patients, 3 of which were confirmed on cTTE. cTTE detected a PFO in 12/59 (20%) patients. Sensitivity and specificity of cardiac CT were 25% (95% CI 5-57%) and 96% (95% CI 85-99%), respectively. Positive and negative predictive values were 59% (95% CI 14-95) and 84% (95% CI 71-92). CONCLUSION Prospective ECG-gated cardiac CT acquired during the acute stroke imaging protocol does not appear to be a suitable screening method for PFO due to its low sensitivity. Our data suggest that if cardiac CT is used as a first-line screening method for cardioembolism, additional echocardiography remains indicated in young patients with cryptogenic stroke, in whom PFO detection would have therapeutic consequences. These results need to be confirmed in larger cohorts.
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Affiliation(s)
- L A Rinkel
- Department of Neurology, Amsterdam University Medical Centres, University of Amsterdam, Location AMC, 1105 AZ, Amsterdam, The Netherlands
| | - B J Bouma
- Department of Cardiology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - S M Boekholdt
- Department of Cardiology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - C F P Beemsterboer
- Department of Neurology, Amsterdam University Medical Centres, University of Amsterdam, Location AMC, 1105 AZ, Amsterdam, The Netherlands
| | - N H J Lobé
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - L F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - H A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - C B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Y B W E M Roos
- Department of Neurology, Amsterdam University Medical Centres, University of Amsterdam, Location AMC, 1105 AZ, Amsterdam, The Netherlands
| | - A van Randen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - R N Planken
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - J M Coutinho
- Department of Neurology, Amsterdam University Medical Centres, University of Amsterdam, Location AMC, 1105 AZ, Amsterdam, The Netherlands.
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5
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Zhou F, Yuan Z, Liu X, Yu K, Li B, Li X, Liu X, Cheng G. Evaluation of atrial anatomical remodeling in atrial fibrillation with machine-learned morphological features. Int J Comput Assist Radiol Surg 2023; 18:603-610. [PMID: 36272019 DOI: 10.1007/s11548-022-02776-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To elucidate the role of atrial anatomical remodeling in atrial fibrillation (AF), we proposed an automatic method to extract and analyze morphological characteristics in left atrium (LA), left atrial appendage (LAA) and pulmonary veins (PVs) and constructed classifiers to evaluate the importance of identified features. METHODS The LA, LAA and PVs were segmented from contrast computed tomography images using either a commercial software or a self-adaptive algorithm proposed by us. From these segments, geometric and fractal features were calculated automatically. To reduce the model complexity, a feature selection procedure is adopted, with the important features identified via univariable analysis and ensemble feature selection. The effectiveness of this approach is well illustrated by the high accuracy of our models. RESULTS Morphological features, such as LAA ostium dimensions and LA volume and surface area, statistically distinguished ([Formula: see text]) AF patients or AF with LAA filling defects (AF(def+)) patients among all patients. On the test set, the best model to predict AF among all patients had an area under the receiver operating characteristic curve (AUC) of 0.91 (95% CI, 0.8-1) and the best model to predict AF(def+) among all patients had an AUC of 0.92 (95% CI, 0.81-1). CONCLUSION This study automatically extracted and analyzed atrial morphology in AF and identified atrial anatomical remodeling that statistically distinguished AF or AF(def+). The importance of identified atrial morphological features in characterizing AF or AF(def+) was validated by corresponding classifiers. This work provides a good foundation for a complete computer-assisted diagnostic workflow of predicting the occurrence of AF or AF(def+).
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Affiliation(s)
- Fanli Zhou
- Department of Radiology, Peking University Shenzhen Hospital, Futian, Shenzhen, 518036, Guangdong, China.
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Nanshan, Shenzhen, 518055, Guangdong, China.
| | - Zhidong Yuan
- Department of Radiology, Peking University Shenzhen Hospital, Futian, Shenzhen, 518036, Guangdong, China
| | - Xianglin Liu
- Center for Artificial Intelligence, Peng Cheng Laboratory, Nanshan, Shenzhen, 518066, Guangdong, China
| | - Keyan Yu
- Department of Radiology, Peking University Shenzhen Hospital, Futian, Shenzhen, 518036, Guangdong, China
| | - Bowei Li
- Department of Radiology, Peking University Shenzhen Hospital, Futian, Shenzhen, 518036, Guangdong, China
| | - Xingyan Li
- Ultrasound Department, Chenzhou No. 1 People's Hospital, Beihu, Chenzhou, 424300, Hunan, China
| | - Xin Liu
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Nanshan, Shenzhen, 518055, Guangdong, China
| | - Guanxun Cheng
- Department of Radiology, Peking University Shenzhen Hospital, Futian, Shenzhen, 518036, Guangdong, China.
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6
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Racharla L, Kher A, Patel Z, Maitz T, Kluck B. The Hype Surrounding Patent Foramen Ovale Closure and Cryptogenic Stroke: A Walk Through History. Heart Int 2022; 16:59-63. [DOI: 10.17925/hi.2022.16.1.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/04/2022] [Indexed: 11/24/2022] Open
Abstract
Cryptogenic stroke (CS) represents one-third of all ischaemic strokes. Studies have shown approximately that half of patients with CS have concomitant patent foramen ovale (PFO), with clear data supporting paradoxical embolization as an aetiology of CS. This article is the first of a multi-part review and will detail the history of PFO closure and the clinical trials that have evaluated the efficacy of PFO device closure. Data favour PFO closure in CS for reducing stroke in appropriate patients and should be considered as a treatment modality.
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7
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Yu S, Zhang H, Li H. Cardiac Computed Tomography Versus Transesophageal Echocardiography for the Detection of Left Atrial Appendage Thrombus: A Systemic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e022505. [PMID: 34796743 PMCID: PMC9075398 DOI: 10.1161/jaha.121.022505] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background Transesophageal echocardiography (TEE) has been considered the gold standard for left atrial appendage (LAA) thrombus detection. Nevertheless, TEE may sometimes induce discomfort and cause complications. Cardiac computed tomography has been studied extensively for LAA thrombus detection. We performed this systemic review and meta-analysis to assess the diagnostic accuracy of cardiac computed tomography for LAA thrombus detection compared with TEE. Methods and Results A systemic search was conducted in the PubMed, Embase, and Cochrane Library databases from January 1977 to February 2021. Studies performed for assessment diagnostic accuracy of cardiac computed tomography on LAA thrombus compared with TEE were included. Summary sensitivity, specificity, and posterior probability of LAA thrombus was calculated by using bivariate random-effects model. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used for the quality assessment. A total of 27 studies involving 6960 patients were included in our study. The summary sensitivity of early imaging studies was 0.95 (95% CI, 0.79-0.99), and the specificity was 0.89 (95% CI, 0.85-0.92). The positive posterior probability was 19.11%, and the negative posterior probability was 0.16%. The summary sensitivity of delayed imaging studies was 0.98 (95% CI, 0.92-1.00), and the specificity was 1.00 (95% CI, 0.98-1.00). The positive posterior probability was 95.76%, and the negative posterior probability was 0.12%. The delayed imaging method significantly improved the specificity (1.00 versus 0.89; P<0.05) and positive posterior probability (95.76% versus 19.11%; P<0.05). Conclusions Cardiac computed tomography with a delayed imaging is a reliable alternative to TEE. It may save the patient and health care from an excess TEE. Registration URL: https://www.crd.york.ac.uk/PROSPERO; Unique identifier: CRD42021236352.
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Affiliation(s)
- Shandong Yu
- Department of CardiologyCardiovascular CenterBeijing Friendship HospitalBeijingChina
| | - Heping Zhang
- Department of CardiologyCardiovascular CenterBeijing Friendship HospitalBeijingChina
| | - Hongwei Li
- Department of CardiologyCardiovascular CenterBeijing Friendship HospitalBeijingChina
- Department of Internal MedicineMedical Health CenterBeijing Friendship HospitalBeijingChina
- Beijing Key Laboratory of Metabolic Disorder‐Related Cardiovascular DiseaseBeijingChina
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8
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Molina-Fuentes MF, Neumann R, Behringer W, Franz M, Schulze PC, Witte OW, Günther A, Klingner C, Lehmkuhl L, Steiniger B, Teichgräber U, Rod JE, Mayer TE. Feasibility of the Big 5-Jena eCS Protocol : First Experience Implementing a New Extended CT Protocol in the Initial Diagnostics of Ischemic Stroke. Clin Neuroradiol 2021; 31:901-909. [PMID: 34379134 PMCID: PMC8356684 DOI: 10.1007/s00062-021-01058-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/18/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE The most common protocols in the initial diagnostic of acute ischemic stroke do not assess cardiogenic or aortic causes of embolism. These are usually evaluated later by transthoracic (TTE) or transesophageal (TEE) echocardiography. This study aimed to evaluate the feasibility of a diagnostic tool for thoracic cardiovascular thrombi according to the first experience with a new extended cardio-stroke protocol (Big 5-Jena eCS protocol) in acute stroke patients. METHODS Retrospective analyses of the tomography scans database of the Jena University Hospital were performed. We included a total of 67 patients in the feasibility analyses, based on the evaluation of three outcomes. RESULTS Primary outcome: the Big 5-Jena eCS protocol was able to detect thoracic cardiovascular thrombi in a total of 20 patients in different locations including the arch of the aorta, the aortic valve, the left atrium, the left atrial appendage, the left ventricle, and the pulmonary arteries. Secondary outcome: implementating the protocol did not result in a significant elevation of the radiation exposure compared to traditional protocols. Tertiary outcome: the new protocol identified seven cases that were considered negative by echocardiography. CONCLUSION The implementation of an extended cardio-stroke protocol is feasible, no significantly time-consuming, acquiring assessable imaging, and maintaining radiation exposure acceptable. The Big 5-Jena eCS protocol was also able to detect some thrombi not reported by TTE or TEE; however, due to our data's explorative character, a conclusive comparison with cardiac ultrasound is not possible. A prospective pilot study and clinical trials should be conducted to assess the diagnostic accuracy of this protocol compared to echocardiography and determine the potential impact on diagnostic and treatment decisions.
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Affiliation(s)
- Moisés F Molina-Fuentes
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany. .,Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.
| | - Rotraud Neumann
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Wilhelm Behringer
- Emergency Department, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Albrecht Günther
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Carsten Klingner
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Lukas Lehmkuhl
- Clinic for Radiology, Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Beatrice Steiniger
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Ulf Teichgräber
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - J E Rod
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Thomas E Mayer
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
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9
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Cohen A, Donal E, Delgado V, Pepi M, Tsang T, Gerber B, Soulat-Dufour L, Habib G, Lancellotti P, Evangelista A, Cujec B, Fine N, Andrade MJ, Sprynger M, Dweck M, Edvardsen T, Popescu BA. EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2021; 22:e24-e57. [PMID: 33709114 DOI: 10.1093/ehjci/jeab008] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 12/28/2022] Open
Abstract
Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.
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Affiliation(s)
- Ariel Cohen
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20141, Milan, Italy
| | - Teresa Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvainAv Hippocrate 10/2803, B-1200 Brussels, Belgium
| | - Laurie Soulat-Dufour
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Gilbert Habib
- Aix Marseille Univ, IRD, MEPHI, IHU-Méditerranée Infection, APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU SartTilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Arturo Evangelista
- Servei de Cardiologia. Hospital Universitari Vall d'Hebron-VHIR. CIBER-CV. Pº Vall d'Hebron 119. 08035. Barcelona. Spain
| | - Bibiana Cujec
- Division of Cardiology, University of Alberta, 2C2.50 Walter Mackenzie Health Sciences Center, 8440 112 St NW, Edmonton, Alberta, Canada T6G 2B7
| | - Nowell Fine
- University of Calgary, Libin Cardiovascular Institute, South Health Campus, 4448 Front Street Southeast, Calgary, Alberta T3M 1M4, Canada
| | - Maria Joao Andrade
- Maria Joao Andrade Cardiology Department, Hospital de Santa Cruz-Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos 2790-134 Carnaxide, Portugal
| | - Muriel Sprynger
- Department of Cardiology-Angiology, University Hospital Liège, Liège, Belgium
| | - Marc Dweck
- British Heart Foundation, Centre for Cardiovascular Science, Edinburgh and Edinburgh Imaging Facility QMRI, University of Edinburgh, United Kingdom
| | - Thor Edvardsen
- Faculty of medicine, Oslo University, Oslo, Norway and Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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10
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Schnabel RB, Camen S, Knebel F, Hagendorff A, Bavendiek U, Böhm M, Doehner W, Endres M, Gröschel K, Goette A, Huttner HB, Jensen C, Kirchhof P, Korosoglou G, Laufs U, Liman J, Morbach C, Nabavi DG, Neumann-Haefelin T, Pfeilschifter W, Poli S, Rizos T, Rolf A, Röther J, Schäbitz WR, Steiner T, Thomalla G, Wachter R, Haeusler KG. Expert opinion paper on cardiac imaging after ischemic stroke. Clin Res Cardiol 2021; 110:938-958. [PMID: 34143285 PMCID: PMC8238761 DOI: 10.1007/s00392-021-01834-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/01/2021] [Indexed: 12/19/2022]
Abstract
This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
| | - Stephan Camen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Knebel
- Department of Cardiology and Angiology, University of Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Michael Böhm
- Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg (Saar) , Germany
| | - Wolfram Doehner
- Berlin Institute of Health, Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany.,Klinik Und Hochschulambulanz Für Neurologie Mit Abteilung Für Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany.,ExcellenceCluster NeuroCure, Berlin, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Department of Cardiology & Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Gießen, Gießen, Germany
| | - Christoph Jensen
- B. Braun Ambulantes Herzzentrum Kassel MVZ GmbH, Kassel, Germany.,Ruhr University Bochum, Bochum, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Grigorios Korosoglou
- Department of Cardiology and Vascular Medicine, GRN Hospital Weinheim, Weinheim, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center and Department for Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Tobias Neumann-Haefelin
- Department of Neurology, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, Goethe-University Hospital Frankfurt, Frankfurt, Germany.,Department of Neurology and Clinical Neurophysiology, Klinikum Lüneburg, Lüneburg, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff-Heart-Center, Bad Nauheim, Germany and Campus Kerckhoff Justus-Liebig-University, Gießen, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Wolf Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany.,Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany.,University Medical Center Goettingen, Göttingen, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany. .,Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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11
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Predictive Value of Cardiac CTA, Cardiac MRI, and Transthoracic Echocardiography for Cardioembolic Stroke Recurrence. AJR Am J Roentgenol 2021; 217:336-346. [PMID: 32936016 DOI: 10.2214/ajr.20.23903] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Transthoracic echocardiography (TTE) is the standard of care for initial evaluation of patients with suspected cardioembolic stroke. Although TTE is useful for assessing certain sources of cardiac emboli, its diagnostic capability is limited in the detection of other sources, including left atrial thrombus and aortic plaques. OBJECTIVE. The purpose of this article was to investigate sensitivity, specificity, and predictive value of cardiac CTA (CCTA), cardiac MRI (CMRI), and TTE for recurrence in patients with suspected cardioembolic stroke. METHODS. We retrospectively included 151 patients with suspected cardioembolic stroke who underwent TTE and either CMRI (n = 75) or CCTA (n = 76) between January 2013 and May 2017. We evaluated for the presence of left atrial thrombus, left ventricular thrombus, vulnerable aortic plaque, cardiac tumors, and valvular vegetation as causes of cardioembolic stroke. The end point was stroke recurrence. Sensitivity, specificity, PPV, and NPV for recurrent stroke were calculated; the diagnostic accuracy of CMRI, CCTA, and TTE was compared between and within groups using AUC. RESULTS. Twelve and 14 recurrent strokes occurred in the CCTA and CMRI groups, respectively. Sensitivity, specificity, PPV, and NPV were 33.3%, 93.7%, 50.0%, and 88.2% for CCTA; 14.3%, 80.3%, 14.3%, and 80.3% for CMRI; 14.3%, 83.6%, 16.7%, and 80.9% for TTE in the CMRI group; and 8.3%, 93.7%, 20.0%, and 84.5% for TTE in the CCTA group. Accuracy was not different (p > .05) between CCTA (AUC = 0.63; 95% CI, 0.49-0.77), CMRI (0.53; 95% CI, 0.42-0.63), TTE in the CMRI group (0.51; 95% CI, 0.40-0.61), and TTE in the CCTA group (0.51; 95% CI, 0.42-0.59). In the CCTA group, atrial and ventricular thrombus were detected by CCTA in three patients and TTE in one patient; in the CMRI group, thrombus was detected by CMRI in one patient and TTE in two patients. CONCLUSION. CCTA, CMRI, and TTE showed comparably high specificity and NPV for cardioembolic stroke recurrence. CCTA and CMRI may be valid alternatives to TTE. CCTA may be preferred given potentially better detection of atrial and ventricular thrombus. CLINICAL IMPACT. CCTA and CMRI have similar clinical performance as TTE for predicting cardioembolic stroke recurrence. This observation may be especially important when TTE provides equivocal findings.
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12
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Practicability and Diagnostic Yield of One-Stop Stroke CT with Delayed-Phase Cardiac CT in Detecting Major Cardioembolic Sources of Acute Ischemic Stroke : A Proof of Concept Study. Clin Neuroradiol 2021; 31:911-920. [PMID: 33688981 PMCID: PMC8648696 DOI: 10.1007/s00062-021-01003-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 02/08/2021] [Indexed: 12/21/2022]
Abstract
Purpose 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. Material and Methods 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. Results 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. Conclusion 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.
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13
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Subahi EA, Kumar N, Hamid AM, Elmahadi MS, Yassin MA. Ischemic colitis and atrial septal aneurysm as a potential cause of systemic thromboembolism. Clin Case Rep 2021; 9:1742-1747. [PMID: 33768927 PMCID: PMC7981700 DOI: 10.1002/ccr3.3889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 01/05/2021] [Accepted: 01/22/2021] [Indexed: 11/11/2022] Open
Abstract
Atrial septal aneurysm is a rare cardiac abnormality with thromboembolic potential and should be considered in a patient with ischemic colitis with no obvious risk factors.
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Affiliation(s)
- Eihab A. Subahi
- Department of Internal MedicineHamad Medical CorporationDohaQatar
| | - Narinder Kumar
- Department of cardiologyAlkhor HospitalHamad Medical CorporationDohaQatar
| | - Abdulwahab M. Hamid
- Department of Gastroenterology and HepatologyAlkhor HospitalHamad Medical CorporationDohaQatar
| | - Mohamed S. Elmahadi
- Department of General MedicineAlkhor HospitalHamad Medical CorporationDohaQatar
| | - Mohamed A. Yassin
- Department of Medical OncologyNational Center for Cancer Care and ResearchHamad Medical CorporationDohaQatar
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14
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Guglielmi V, Rinkel LA, Groeneveld NS, Lobé NH, Boekholdt SM, Bouma BJ, Beenen LF, Marquering HA, Majoie CB, Roos YB, van Randen A, Planken RN, Coutinho JM. Mind the Heart: Electrocardiography-gated cardiac computed tomography-angiography in acute ischaemic stroke-rationale and study design. Eur Stroke J 2021; 5:441-448. [PMID: 33598563 PMCID: PMC7856589 DOI: 10.1177/2396987320962911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/23/2020] [Indexed: 11/16/2022] Open
Abstract
Rationale About one-third of ischaemic strokes are caused by cardioembolism, and a substantial proportion of cryptogenic strokes likely also originate from the heart or aortic arch. Early determination of aetiology is important to optimise management. Computed Tomography-angiography of the heart is emerging as an alternative to echocardiography to detect cardio-aortic sources of embolism in stroke patients, but its diagnostic yield in acute ischaemic stroke has not been thoroughly assessed.Hypothesis: We hypothesise that electrocardiography-gated computed tomography-angiography of the heart and aortic arch, acquired in the acute phase in patients with ischaemic stroke, has a higher diagnostic yield than transthoracic echocardiography as a first-line screening method for detection of cardio-aortic sources of embolism. Methods and design Mind the Heart is a single-centre prospective observational cohort study. We will include consecutive adult patients with acute ischaemic stroke who are potentially eligible for reperfusion therapy. Patients undergo non-electrocardiography-gated computed tomography-angiography of the aortic arch, cervical and intracranial arteries, directly followed by prospective sequential electrocardiography-gated cardiac computed tomography-angiography. Routine work-up for cardioembolism including 12-leads electrocardiography, Holter electrocardiography and transthoracic echocardiography is performed as soon as possible. The primary endpoint is the proportion of patients with a predefined high-risk cardio-aortic source of embolism on computed tomography-angiography versus transthoracic echocardiography in patients who underwent both investigations. Based on an expected 5% additional yield of computed tomography-angiography, a sample size of 450 patients is required. Conclusions The Mind the Heart study will generate a reliable estimate of the diagnostic yield of echocardiography-gated cardio-aortic computed tomography-angiography performed in the acute phase of ischaemic stroke.
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Affiliation(s)
- Valeria Guglielmi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Leon A Rinkel
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Nick Hj Lobé
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo Fm Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo Bwem Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adrienne van Randen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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15
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Holswilder G, Wermer MJ, Holman ER, Kruyt ND, Kroft LJ, van Walderveen MA. CT Angiography of the Heart and Aorta in TIA and Ischaemic Stroke: Cardioembolic Risk Sources and Clinical Implications. J Stroke Cerebrovasc Dis 2020; 29:105326. [PMID: 33010723 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Cardiac emboli are important causes of (recurrent) ischaemic stroke. Aorta atherosclerosis might also be associated with an increased risk of stroke recurrence. This study aimed to evaluate the yield and clinical implications of CT-angiography (CTA) of the heart and aorta in the diagnostic workup of transient ischaemic attack (TIA) or ischaemic stroke. METHODS CTA of the heart and aortic arch was performed in TIA/ischaemic stroke patients, in addition to routine diagnostic workup. Occurrence of cardioembolic (CE) risk sources and complex aortic plaques were assessed. Implications of cardiac CTA for therapeutic management were evaluated RESULTS: Sixty-seven patients were included (TIA n = 33, ischaemic stroke n = 34) with a mean age of 68 years (range 51-89) and median NIHSS of 0 (interquartile range 0-2). CE risk sources were detected in 29 (43%) patients. An intracardiac thrombus was present in 2 patients (3%; TIA 0%; ischaemic stroke 6%). Medium/low-risk CE sources included mitral annular calcification (9%), aortic valve calcification (18%) and patent foramen ovale (18%). Complex aortic plaque was identified in 16 patients (24%). In two patients with an intracardiac thrombus, therapeutic management changed from antiplatelet to oral anticoagulation. CONCLUSIONS CTA of the heart and aorta has a high yield for detection of embolic risk sources in TIA/ischaemic stroke, with clinical consequences for 6% of ischaemic stroke patients. Implementation of CTA of the heart and aorta in the acute stroke setting seems valuable, but cost-effectiveness of this approach remains to be determined.
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Affiliation(s)
- Ghislaine Holswilder
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Eduard R Holman
- Department of Cardiology, Leiden University Medical Center Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Lucia Jm Kroft
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Marianne Aa van Walderveen
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
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16
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Abstract
PURPOSE OF REVIEW Cardiac imaging after ischemic stroke or transient ischemic attack (TIA) is used to identify potential sources of cardioembolism, to classify stroke etiology leading to changes in secondary stroke prevention, and to detect frequent comorbidities. This article summarizes the latest research on this topic and provides an approach to clinical practice to use cardiac imaging after stroke. RECENT FINDINGS Echocardiography remains the primary imaging method for cardiac work-up after stroke. Recent echocardiography studies further demonstrated promising results regarding the prediction of non-permanent atrial fibrillation after ischemic stroke. Cardiac magnetic resonance imaging and computed tomography have been tested for their diagnostic value, in particular in patients with cryptogenic stroke, and can be considered as second line methods, providing complementary information in selected stroke patients. Cardiac imaging after ischemic stroke or TIA reveals a potential causal condition in a subset of patients. Whether systematic application of cardiac imaging improves outcome after stroke remains to be established.
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Affiliation(s)
- S Camen
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research) (partner site Hamburg/Kiel/Luebeck), Berlin, Germany
| | - K G Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - R B Schnabel
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.
- DZHK (German Center for Cardiovascular Research) (partner site Hamburg/Kiel/Luebeck), Berlin, Germany.
- University Heart Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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17
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Arabia L, Lucino S, Tibaldi J, Gambi DL, García R, Pérez ME, Bottello F. Use of Computed Tomography Scan to Rule Out Phantom Thrombus in the Left Atrial Appendage. JOURNAL OF CARDIAC ARRHYTHMIAS 2020. [DOI: 10.24207/jca.v33i1.3392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Occurrence of left atrial appendage (LAA) thrombus is a frequent complication of atrial fibrillation (AF) and it increase thromboembolic risk. Transesophageal echocardiography (TEE) is considered the gold standard to ensure that this chamber is thrombus free. Multidetector computed tomography (CT) scan has some advantages such the possibility to get 3D reconstruction and explore another structures in relationship with the LAA. However, lack of specificity in case of false positive images with filling defects due to slow velocities in the LAA. Methods and Results: 34 patiens with suspected thrombus by a previous CT scan or transesophageal echo were included in analisys. The aim of study was evaluated the utility of CT scan with delayed acquisition protocol to exclude LAA thrombus. In all of patients, complete LAA filling was observed, with a sensitivity, specificity and negative predictive value of 100% to differentiate circulatory stasis from thrombus. Conclusion: Perform a CT scan with a delayed acquisition protocol and in prone position are safe techniques to rule out fake thrombus.
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18
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Groeneveld NS, Guglielmi V, Leeflang MMG, Matthijs Boekholdt S, Nils Planken R, Roos YBWEM, Majoie CBLM, Coutinho JM. CT angiography vs echocardiography for detection of cardiac thrombi in ischemic stroke: a systematic review and meta-analysis. J Neurol 2020; 267:1793-1801. [PMID: 32140869 PMCID: PMC7293690 DOI: 10.1007/s00415-020-09766-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Cardiac thrombi are an important cause of embolic stroke. We studied the diagnostic yield and diagnostic accuracy of cardiac CT angiography (CTA) compared to echocardiography for detection of cardiac thrombi in ischemic stroke patients. METHODS We performed a systematic review and meta-analysis of the literature on cardiac CTA versus echocardiography for detection of cardiac thrombi in ischemic stroke patients. We included studies (N ≥ 20) in which both cardiac CTA (index test) and echocardiography (reference test) were performed and data on cardiac thrombi were reported. Results were stratified for type of echocardiography: transesophageal (TEE) vs transthoracic (TTE). RESULTS Out of 1530 studies, 14 were included (all single center cohort studies), with data on 1568 patients. Mean age varied between 52 and 69 years per study and 66% were men. Reported time intervals ranged from 0 to 21 days between stroke and first test, and from 0 to 199 days between tests. In ten studies that compared CTA to TEE, CTA detected cardiac thrombi in 87/1385 (6.3%) patients versus 68/1385 (4.9%) on TEE (p < 0.001). In four studies comparing CTA to TTE, CTA detected thrombi in 23/183 (12.5%) patients versus 12/183 (6.6%) on TTE (p = 0.010). Pooled sensitivity and specificity of CTA versus TEE were 86.0% (95% CI 65.6-95.2) and 97.4% (95% CI 95.0-98.7), respectively. CONCLUSIONS CTA may be a promising alternative to echocardiography for detection of cardiac thrombi in patients with ischemic stroke, especially now that CTA is standard care for patient selection for endovascular treatment. However, studies were too heterogeneous and of insufficient methodological quality to draw firm conclusions. Large, prospective studies on this topic are warranted.
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Affiliation(s)
| | - Valeria Guglielmi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mariska M G Leeflang
- Department of Clinical Epidemiology and Biostatistics and Bioinformatics Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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19
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Pathan F, Hecht H, Narula J, Marwick TH. Roles of Transesophageal Echocardiography and Cardiac Computed Tomography for Evaluation of Left Atrial Thrombus and Associated Pathology: A Review and Critical Analysis. JACC Cardiovasc Imaging 2019; 11:616-627. [PMID: 29622180 DOI: 10.1016/j.jcmg.2017.12.019] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 12/21/2017] [Indexed: 01/23/2023]
Abstract
Evaluation of the left atrium and left atrial appendage for the presence of thrombus prior to cardioversion and pulmonary vein isolation, and of the entire heart for embolic sources in the setting of cryptogenic stroke, has long been standard medical care. Guidelines have uniformly recommended transesophageal echocardiography (TEE) to accomplish these goals. In recent years, computed tomographic angiography has demonstrated diagnostic accuracy similar to that of TEE for the detection of thrombus. Analysis of the pertinent data and relative merits of the 2 technologies leads to the conclusions that: 1) both modalities have some unique, nonoverlapping capabilities that may dictate their use in specific situations; 2) computed tomographic angiography is a reasonable alternative to TEE when the primary aim is to exclude left atrial and left atrial appendage thrombus and in patients in whom the risks associated with TEE outweigh the benefits; and 3) both options should be discussed with the patient in the setting of shared decision making.
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Affiliation(s)
- Faraz Pathan
- Menzies Institute for Medical Research, Hobart, Australia
| | - Harvey Hecht
- Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York
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20
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Abstract
About 20–25% of all ischemic strokes are of cardioembolic etiology, with atrial fibrillation and heart failure as the most common underlying pathologies. Diagnostic work-up by noninvasive cardiac imaging is essential since it may lead to changes in therapy, e.g., in—but not exclusively—secondary stroke prevention. Echocardiography remains the cornerstone of cardiac imaging after ischemic stroke, with the combination of transthoracic and transesophageal echocardiography as gold standard thanks to their high sensitivity for many common pathologies. Transesophageal echocardiography should be considered as the initial diagnostic tool when a cardioembolic source of stroke is suspected. However, to date, there is no proven benefit of transesophageal echocardiography-related therapy changes on the main outcomes after ischemic stroke. Based on the currently available data, cardiac computed tomography and magnetic resonance imaging should be regarded as complementary methods to echocardiography, providing additional information in specific situations; however, they cannot be recommended as first-line modalities.
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Affiliation(s)
- S Camen
- Department of General and Interventional Cardiology, Building O70, University Heart Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - K G Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - R B Schnabel
- Department of General and Interventional Cardiology, Building O70, University Heart Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany. .,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany.
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21
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Kim IC, Chang HJ, Cho IJ, Shim CY, Hong GR, Heo JH, Nam HS, Kim YJ, Choi BW, Chung N. Benefit of Four-Dimensional Computed Tomography Derived Ejection Fraction of the Left Atrial Appendage to Predict Thromboembolic Risk in the Patients with Valvular Heart Disease. Korean Circ J 2018; 49:173-180. [PMID: 30468031 PMCID: PMC6351282 DOI: 10.4070/kcj.2018.0152] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/26/2018] [Accepted: 09/18/2018] [Indexed: 11/11/2022] Open
Abstract
Background and Objectives Decreased left atrial appendage (LAA) emptying velocity in transesophageal echocardiography (TEE) is related with higher incidence of thrombus and increased risk of stroke. Patients with valve disease are at higher risk of thrombus formation before and after surgery. The aim of this study was to investigate the role of 4-dimensional cardiac computed tomography (4DCT) to predict the risk of thrombus formation. Methods Between March 2010 to March 2015, total of 62 patients (mean 60±15 years old, male: 53.2%) who underwent 4DCT and TEE for cardiac valve evaluation before surgery were retrospectively included in the current study. Fractional area change in TEE view and emptying velocity at left atrial appendage in TEE view (VeTEE) were measured. Ejection fraction (EF) of left atrial appendage in computed tomography (EFCT) was calculated by 4DCT with full volume analysis. The best cut-off value of EFCT predicting presence of spontaneous echo contrast (SEC) or thrombus was evaluated, and correlation between the parameters were also estimated. Results SEC or thrombus was observed in 45.2%. EFCT and VeTEE were significantly correlated (r=0.452, p<0.001). However, fractional area change measured by TEE showed no correlation with VeTEE (r=0.085, p=0.512). EFCT <37.5% best predicted SEC or thrombus in the patients with valve disease who underwent 4DCT and TEE (area under the curve, 0.654; p=0.038). Conclusions In the patients who underwent 4DCT for cardiac valve evaluation before surgery, EFCT by volume analysis might have additional role to evaluate LAA function and estimate the risk of thrombus.
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Affiliation(s)
- In Cheol Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.,Division of Cardiology, Department of Internal Medicine, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, Korea
| | - Hyuk Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - In Jeong Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Geu Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Wook Choi
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Namsik Chung
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
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22
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Song I, Kang JH, Kim MY, Hwang HK, Kim HY, Ko SM. Diagnostic Accuracy of Electrocardiogram-Gated Thoracic Computed Tomography Angiography without Heart Rate Control for Detection of Significant Coronary Artery Stenosis in Patients with Acute Ischemic Stroke: A Comparative Study. Korean J Radiol 2018; 19:905-915. [PMID: 30174480 PMCID: PMC6082753 DOI: 10.3348/kjr.2018.19.5.905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 03/03/2018] [Indexed: 11/16/2022] Open
Abstract
Objective To compare the diagnostic performance of electrocardiogram (ECG)-gated thoracic computed tomography angiography (TCTA) without heart rate (HR) control in ischemic stroke patients with coronary CTA (CCTA) in non-stroke patients for detection of significant coronary artery stenosis. Materials and Methods From September 2009 through August 2014, we retrospectively enrolled 138 consecutive patients diagnosed with acute ischemic stroke who had undergone ECG-gated TCTA and conventional coronary angiography (CCA). Over the same period, we selected 167 non-stroke patients with suspected or known coronary artery disease who had undergone CCTA and CCA. With CCA as the reference standard, the diagnostic performance of TCTA and CCTA for identification of significant coronary stenosis (diameter reduction ≥ 50%) was calculated. Results There was no significant difference in baseline characteristics between TCTA (n = 132) and CCTA (n = 164), except for the higher prevalence of atrial fibrillation in the stroke group. There was significant difference (p < 0.001) between TCTA and CCTA in average HR (68 ± 12 vs. 61 ± 10 beats per minute) and image quality score (1.3 ± 0.6 vs. 1.2 ± 0.6). Significant coronary stenosis was identified in 101 (77%) patients, 179 (45%) vessels, and 293 (15%) segments of stroke patients, and in 136 (83%) patients, 259 (53%) vessels, and 404 (16%) segments of non-stroke patients. Diagnostic performance on a per-vessel and per-patient basis was similar in both TCTA and CCTA groups. There was only significant difference in area under receiver-operating characteristic curve between TCTA and CCTA groups (0.79 vs. 0.87, p < 0.001) on per-segment basis. Conclusion Electrocardiogram-gated TCTA without HR control facilitates the identification of significant coronary stenosis in patients with ischemic stroke.
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Affiliation(s)
- Inyoung Song
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Ji Hun Kang
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Mi Young Kim
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Hweung Kon Hwang
- Department of Cardiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Han Young Kim
- Department of Neurology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
| | - Sung Min Ko
- Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul 05030, Korea
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23
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Kauw F, Dankbaar JW, Habets J, Cramer MJM, de Jong HWAM, Velthuis BK, Kappelle LJ. A Change of Heart: Yield of Cardiac Imaging in Acute Stroke Workup. Case Rep Neurol 2018; 10:118-123. [PMID: 29928217 PMCID: PMC6006656 DOI: 10.1159/000489254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 04/05/2018] [Indexed: 11/19/2022] Open
Abstract
This case report describes a patient who experienced a recurrent ischemic stroke within 24 h. Dual-energy computed tomography (DECT) angiography on admission showed 2 intracardiac thrombi, 1 in the left ventricle and 1 in the left atrial appendage. Following the second ischemic event, repeated DECT angiography showed that the ventricular thrombus had considerably diminished, suggesting that the recurrent brain infarction was caused by cardioembolism. This case emphasizes (1) the potential benefit of cardiac evaluation through CT angiography in the acute stroke setting, and (2) the use of DECT angiography for the detection of thrombus and the differentiation between thrombus, the myocardial wall, and a slow flow of contrast.
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Affiliation(s)
- Frans Kauw
- Department of Radiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Jan W Dankbaar
- Department of Radiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Jesse Habets
- Department of Radiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Maarten J M Cramer
- Department of Cardiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Hugo W A M de Jong
- Department of Radiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
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24
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Zhai Z, Tang M, Zhang S, Fang P, Jia Y, Feng T, Wang J. Transoesophageal echocardiography prior to catheter ablation could be avoided in atrial fibrillation patients with a low risk of stroke and without filling defects in the late-phase MDCT scan: A retrospective analysis of 783 patients. Eur Radiol 2017; 28:1835-1843. [PMID: 29218612 DOI: 10.1007/s00330-017-5172-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 10/11/2017] [Accepted: 11/03/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To test whether multidetector computed tomography (MDCT) could completely replace transoesophageal echocardiography (TEE) to detect left atrial appendage (LAA) thrombi in atrial fibrillation (AF) patients using a large sample size. METHODS 783 patients with AF who underwent MDCT and TEE before catheter ablation were retrospectively included. Demographic data were obtained. Two radiologists blinded to clinical data made the imaging diagnosis. RESULTS Most of the patients (96.2 %) had a CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥ 75 years old (doubled), diabetes, stroke/transient ischaemic attack/thromboembolism (doubled), vascular disease, age 65-74 years, female sex) ≤ 3. Eight thrombi were identified by TEE, all of which were detected by MDCT; no thrombus was observed with TEE without the observation of filling defects by late-phase MDCT scanning in any of the patients. Using TEE as reference standard, the sensitivity, specificity, positive predictive value and negative predictive value of MDCT for thrombus detection were 100 %, 95.74 % (95 % CI 94.33 %-97.15 %), 19.51 % (95 % CI 16.73 %-22.29 %) and 100 %, respectively. CONCLUSIONS For AF patients with low risk of stroke, when MDCT images showed no filling defect in the late phase, TEE prior to catheter ablation can be avoided. KEY POINTS • MDCT can help detect the presence of LAA thrombus. • TEE can be avoided when late-phase MDCT shows no filling defect. • TEE is required in patients whose MDCT images indicate thrombus.
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Affiliation(s)
- Zhengqin Zhai
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.167, Beilishi Road, Xicheng District, Beijing, China
| | - Min Tang
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.167, Beilishi Road, Xicheng District, Beijing, China.
| | - Shu Zhang
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.167, Beilishi Road, Xicheng District, Beijing, China
| | - Pihua Fang
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.167, Beilishi Road, Xicheng District, Beijing, China
| | - Yuhe Jia
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.167, Beilishi Road, Xicheng District, Beijing, China
| | - Tianjie Feng
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.167, Beilishi Road, Xicheng District, Beijing, China
| | - Jiande Wang
- Department of Arrhythmia, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, NO.167, Beilishi Road, Xicheng District, Beijing, China
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25
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Yeo LL, Holmin S, Andersson T, Lundström E, Gopinathan A, Lim EL, Leong BS, Kuan WS, Ting E, Tan BY, Eide SE, Tay EL. Nongated Cardiac Computed Tomographic Angiograms for Detection of Embolic Sources in Acute Ischemic Stroke. Stroke 2017; 48:1256-1261. [DOI: 10.1161/strokeaha.117.016903] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/24/2017] [Accepted: 03/01/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
We assessed the feasibility of obtaining diagnostic quality images of the heart and thoracic aorta by extending the
z
axis coverage of a non–ECG-gated computed tomographic angiogram performed in the primary evaluation of acute stroke without increasing the contrast dose.
Methods—
Twenty consecutive patients with acute ischemic stroke within the 4.5 hours of symptom onset were prospectively recruited. We increased the longitudinal coverage to the domes of the diaphragm to include the heart. Contrast administration (Omnipaque 350) remained unchanged (injected at 3–4 mL/s; total 60–80 mL, triggered by bolus tracking). Images of the heart and aorta, reconstructed at 5 mm slice thickness in 3 orthogonal planes, were read by a radiologist and cardiologist, findings conveyed to the treating neurologist, and correlated with the transthoracic or transesophageal echocardiogram performed within the next 24 hours.
Results—
Of 20 patients studied, 3 (15%) had abnormal findings: a left ventricular thrombus, a Stanford type A aortic dissection, and a thrombus of the left atrial appendage. Both thrombi were confirmed by transesophageal echocardiography, and anticoagulation was started urgently the following day. None of the patients developed contrast-induced nephropathy on follow-up. The radiation dose was slightly increased from a mean of 4.26 mSV (range, 3.88–4.70 mSV) to 5.17 (range, 3.95 to 6.25 mSV).
Conclusions—
Including the heart and ascending aorta in a routine non–ECG-gated computed tomographic angiogram enhances an existing imaging modality, with no increased incidence of contrast-induced nephropathy and minimal increase in radiation dose. This may help in the detection of high-risk cardiac and aortic sources of embolism in acute stroke patients.
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Affiliation(s)
- Leonard L.L. Yeo
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Staffan Holmin
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Tommy Andersson
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Erik Lundström
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Anil Gopinathan
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Er Luen Lim
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Benjamin S.H. Leong
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Win Sen Kuan
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Eric Ting
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Benjamin Y.Q. Tan
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Sterling Ellis Eide
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
| | - Edgar L.K. Tay
- From the Division of Neurology, Department of Medicine, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.); Department of Clinical Neuroscience (S.H., T.A., E.L.), Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology (S.H., T.A.) and Department of Neurology (E.L.), Karolinska University Hospital, Stockholm, Sweden; Department of Diagnostic Imaging (A.G., E.T., S.E.E.) and Emergency Medicine Department (E.L.L., B.S.H.L., W.S.K.), National University Hospital, National
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26
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Hur J, Choi BW. Cardiac CT Imaging for Ischemic Stroke: Current and Evolving Clinical Applications. Radiology 2017; 283:14-28. [DOI: 10.1148/radiol.2016152043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jin Hur
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemungu, 120-752, Seoul, Republic of Korea
| | - Byoung Wook Choi
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemungu, 120-752, Seoul, Republic of Korea
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Impact of Implementing Cardiac CT in Evaluating Patients Suspected of Cardioembolic Stroke. J Comput Assist Tomogr 2017; 40:380-6. [PMID: 26854417 DOI: 10.1097/rct.0000000000000369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES In practice, clinical and logistic hurdles may hamper performing transesophageal echocardiography in stroke patients. Cardiac computed tomography (CT) is a recently introduced noninvasive modality able to detect various embolic causes. Thus, we retrospectively assessed possible added values of applying cardiac CT in the real-world work-up of suspected cardioembolic stroke cases. METHODS Forty-seven patients were neurology service referrals for suspected cardioembolic stroke. The CT images and clinical reports of our cardiac CT radiologists were retrospectively evaluated. Cardiac CT was assessed in terms of detecting major embolic potential findings, potentially significant stroke-unrelated findings, and coronary arterial disease (CAD). Computed tomography results were correlated with echocardiographic reports. RESULTS Cardiac CT showed findings of major embolic potential in 10 patients (21%, 5 thrombi cases, 2 vasculitis cases, 1 case of metastasis invading the left superior pulmonary artery, 1 myocardial infarction case, and 1 pulmonary arteriovenous malformations case), none of which were documented in echocardiography reports. Two cases (4%) with findings of major embolic potential where identified on echocardiography but not on CT (1 left atrial appendage thrombus and 1 mitral valve vegetation). Computed tomography of 13 patients (28%) showed 16 potentially significant stroke-unrelated findings. Twenty-one patients (47%) had unexpected CAD on CT, 11 (52%) of which were obstructive. CONCLUSIONS Implementing cardiac CT in assessing patients suspected of cardioembolic stroke added value to echocardiographic evaluation, by detecting major embolic potential findings. In addition, cardiac CT revealed additional potentially significant stroke-unrelated findings and CAD.
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28
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Kim YD, Song D, Nam HS, Choi D, Kim JS, Kim BK, Chang HJ, Choi HY, Lee K, Yoo J, Lee HS, Nam CM, Heo JH. Increased Risk of Cardiovascular Events in Stroke Patients Who had Not Undergone Evaluation for Coronary Artery Disease. Yonsei Med J 2017; 58:114-122. [PMID: 27873503 PMCID: PMC5122626 DOI: 10.3349/ymj.2017.58.1.114] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 07/25/2016] [Accepted: 07/26/2016] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Although asymptomatic coronary artery occlusive disease is common in stroke patients, the long-term advantages of undergoing evaluation for coronary arterial disease using multi-detector coronary computed tomography (MDCT) have not been well established in stroke patients. We compared long-term cardio-cerebrovascular outcomes between patients who underwent MDCT and those who did not. MATERIALS AND METHODS This was a retrospective study in a prospective cohort of consecutive ischemic stroke patients. Of the 3117 patients who were registered between July 2006 and December 2012, MDCT was performed in 1842 patients [MDCT (+) group] and not in 1275 patients [MDCT (-) group]. Occurrences of death, cardiovascular events, and recurrent stroke were compared between the groups using Cox proportional hazards models and propensity score analyses. RESULTS During the mean follow-up of 38.0±24.8 months, 486 (15.6%) patients died, recurrent stroke occurred in 297 (9.5%), and cardiovascular events occurred in 60 patients (1.9%). Mean annual risks of death (9.34% vs. 2.47%), cardiovascular events (1.2% vs. 0.29%), and recurrent stroke (4.7% vs. 2.56%) were higher in the MDCT (-) group than in the MDCT (+) group. The Cox proportional hazards model and the five propensity score-adjusted models consistently demonstrated that the MDCT (-) group was at a high risk of cardiovascular events (hazard ratios 3.200, 95% confidence interval 1.172-8.735 in 1:1 propensity matching analysis) as well as death. The MDCT (-) group seemed to also have a higher risk of recurrent stroke. CONCLUSION Acute stroke patients who underwent MDCT experienced fewer deaths, cardiovascular events, and recurrent strokes during follow-up.
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Affiliation(s)
- Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Dongbeom Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byeong Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Yeon Choi
- Department of Neurology, Kyung Hee University College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kijeong Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Joonsang Yoo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea.
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Wang L, Kadiyala M, Koss E, Yarramaneni A, Rapelje K, Kampfer S, Reichek N, Hoch D, Jayam V, Levine J, Cao JJ. CTA Detection of Left Atrial Stasis and Thrombus in Patients with Atrial Fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:1388-1393. [PMID: 27730660 DOI: 10.1111/pace.12959] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/31/2016] [Accepted: 09/20/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND We investigated computed tomography (CT) angiography (CTA) in assessment of left atrial appendage (LAA) stasis and thrombus in preprocedural evaluation for atrial fibrillation (AF) ablation in a large community cohort. METHODS AND RESULTS We reviewed CTA and transesophageal echocardiographic images obtained in 861 consecutive patients with a history of AF undergoing same-day CTA and transesophageal echocardiogram (TEE) before AF ablation at a single hospital (2006-2013). CTA findings of LAA filling defects from acquisitions without electrocardiogram gating were compared to TEE features of LAA stasis (grade 0-4) and thrombus. Stasis grade 0 or 1 by TEE in the absence of thrombus was defined as a negative result. In addition, LAA peak flow velocity was assessed by TEE. Average age was 61 ± 10 years and 75% were male. On CTA, 161 patients (19%) had LAA filling defects on CTA and 21 had ≥grade 2 stasis on TEE, including two with thrombus, resulting in a positive predictive value of only 13%. However, among 670 CTA-negative patients, 669 (99%) were negative for thrombus or stasis by TEE with one false-negative CTA in a patient with grade 2 stasis by TEE but no thrombus, yielding a negative predictive value of 99.9%. Slow LAA Doppler flow velocity was the most important determinant of false-positive CTA results in multivariate analysis (P < 0.0001) CONCLUSION: LAA filling defects on CT are associated with slow LAA flow velocity. AF patients without LAA filing defects on CT are free of significant stasis and thrombus on TEE. It may be possible to eliminate TEE in up to 80% of AF ablation patients based on negative CTA findings.
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Affiliation(s)
- Lin Wang
- St. Francis Hospital, The Heart Center, Roslyn, New York
| | | | - Elana Koss
- St. Francis Hospital, The Heart Center, Roslyn, New York
| | | | | | | | | | - David Hoch
- St. Francis Hospital, The Heart Center, Roslyn, New York
| | - Vinay Jayam
- St. Francis Hospital, The Heart Center, Roslyn, New York
| | - Joseph Levine
- St. Francis Hospital, The Heart Center, Roslyn, New York
| | - Jie J Cao
- St. Francis Hospital, The Heart Center, Roslyn, New York
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Double-contrast, single-phase computed tomography angiography for ruling out left atrial appendage thrombus prior to atrial fibrillation ablation. Int J Cardiovasc Imaging 2016; 33:121-128. [PMID: 27601228 PMCID: PMC5247541 DOI: 10.1007/s10554-016-0973-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 08/29/2016] [Indexed: 11/26/2022]
Abstract
Prior to atrial fibrillation (AF) ablation, computed tomography angiography (CTA) is increasingly used for left atrial appendage (LAA) thrombus detection. LAA filling defects on CTA may represent thrombus or incomplete contrast mixing with blood. A pre-bolus of contrast material with delay before the CTA contrast bolus can help distinguish between thrombus and incomplete contrast mixing. We present results from a double-contrast, single-phase CTA protocol used in our daily clinical practice. In patients who underwent AF ablation between 2011 and 2015, double-contrast, single-phase CTA was performed prior to ablation. Two contrast boluses (30 and 70 ml) with 25-s interbolus delay were administered followed by prospectively triggered cardiac CTA. Only patients with left atrial (LA) or LAA filling defects underwent transesophageal echocardiography (TEE) to rule out thrombus. Prior to ablation, 605 CTA-scans were performed (median radiation dose: 3.1 mSv). In 579 CTA-scans (95.7 %), the LA and LAA completely filled with contrast. In 26 CTA-scans (4.3 %) the LAA showed a filling defect whereby thrombus could not be excluded. In 2 of those 26 patients (7.7 % and 0.3 % of the total population), TEE verified LAA thrombus. Low-risk LAA filling defects on CTA (n = 7/26) with an inhomogeneous aspect, Houndsfield Unit values >100, and an indefinite border were all caused by incomplete contrast mixing. No thromboembolic complications occurred perioperatively or during 6 months follow-up. Prior to AF ablation, incidence of LAA filling defects on double-contrast, single-phase CTA is low. TEE remains warranted in all but low-risk filling defects to rule out thrombus.
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31
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Zou H, Zhang Y, Tong J, Liu Z. Multidetector computed tomography for detecting left atrial/left atrial appendage thrombus: a meta-analysis. Intern Med J 2016; 45:1044-53. [PMID: 26178177 DOI: 10.1111/imj.12862] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/28/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The diagnostic accuracy of multidetector computed tomography (MDCT) in the detection of left atrial/left atrial appendage (LA/LAA) thrombus had been tested in many studies; however, the results are controversial. AIM The aim of the present study was to evaluate synthetically the diagnostic accuracy of MDCT in LA/LAA thrombus. METHODS PubMed and Embase were searched for published prospective studies which compared computed tomography with transoesophageal echocardiography (TEE) in detecting LA/LAA thrombus prior to March 2014. Descriptive and quantitative information was extracted and MetaDiSc 1.4 was used to perform a meta-analysis. RESULTS Fifteen prospective clinical controlled trials with 2540 patients fulfilled the inclusion criteria. The pooled sensitivities (SEN): 0.957; pooled specificities (SPE): 0.917; pooled positive likelihood ratio (PLR): 22.017; pooled negative likelihood ratio (NLR): 0.060; pooled diagnostic odds ratio (DOR): 437.43; the area under the curve (AUC): 0.9883; Q*-value: 0.9544. However, in the abovementioned indexes, the heterogeneities were statistically significant between studies (P < 0.05, inconsistency index (I(2) ) > 50%). In a sub-analysis of studies in which delayed imaging, electrocardiogram (ECG) gating and heart rate control were performed, not only the diagnostic accuracy, but also the heterogeneities were significantly improved (pooled SEN 0.991; pooled SPE 0.989; pooled PLR 60.768; pooled NLR 0.034; pooled DOR 2561.7; AUC 0.9972; Q*-value 0.9806; all the indexes' P-value were greater than 0.05 and the I(2) were 0%, except for SPE, I(2) = 54.6%). CONCLUSION For patients with TEE intolerance or contraindications, MDCT may be an alternative method, especially when the delayed imaging, ECG gating and heart rate control were performed.
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Affiliation(s)
- H Zou
- Department of Cardiology, The Second Affiliated Hospital/The Second Clinical Institute, Chongqing Medical University, Chongqing, China
| | - Y Zhang
- Department of Cardiology, The Second Affiliated Hospital/The Second Clinical Institute, Chongqing Medical University, Chongqing, China
| | - J Tong
- Department of Respirology, The Second Affiliated Hospital/The Second Clinical Institute, Chongqing Medical University, Chongqing, China
| | - Z Liu
- Department of Cardiology, The Second Affiliated Hospital/The Second Clinical Institute, Chongqing Medical University, Chongqing, China
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Iwasaki K, Matsumoto T, Kawada S. Potential Utility of Multidetector Computed Tomography to Identify both Cardiac Embolic Sources and Coronary Artery Disease in Patients with Embolic Stroke. Cardiology 2015; 133:205-10. [PMID: 26618934 DOI: 10.1159/000441277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 09/23/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Our objective was to study the potential utility of multidetector computed tomography (MDCT) to identify both cardiac embolic sources and coronary artery disease (CAD) in embolic-stroke patients. METHODS We performed MDCT for 184 patients with embolic stroke but without known CAD. Twenty-six patients had atrial fibrillation. We investigated the prevalence of the potential source of the embolism and the coronary characteristics. RESULTS Overall, 64 potential embolic sources were detected in 59 patients (32.1%). Left atrial appendage thrombus, left ventricular thrombus and aortic atheroma were detected in 3.3, 0.5 and 15.8% of patients, respectively. Circulatory stasis and patent foramen ovale were detected in 8.7 and 6.5%, respectively. As for coronary calcium score, only 47 patients (25.5%) had a score of zero and 51 (27.7%) had a score of ≥ 400. Significant CAD was detected in 18 patients (9.8%). One hundred and thirty-seven (74.5%) had coronary plaques. The prevalence of positive remodeling, low-attenuation plaque, spotty calcification and a napkin-ring sign was 7.1, 1.6, 5.4 and 2.7%, respectively. Importantly, only 34 patients (13.0%) had no abnormalities detected by MDCT. CONCLUSIONS Our results suggest that MDCT has potential to identify both cardiac embolic sources and CAD in patients with embolic stroke but without known CAD.
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A low-dose, dual-phase cardiovascular CT protocol to assess left atrial appendage anatomy and exclude thrombus prior to left atrial intervention. Int J Cardiovasc Imaging 2015; 32:347-354. [DOI: 10.1007/s10554-015-0776-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/21/2015] [Indexed: 11/26/2022]
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Lee K, Hur J, Hong SR, Suh YJ, Im DJ, Kim YJ, Hong YJ, Lee HJ, Kim YJ, Lee HS, Hong GR, Choi BW. Predictors of Recurrent Stroke in Patients with Ischemic Stroke: Comparison Study between Transesophageal Echocardiography and Cardiac CT. Radiology 2015; 276:381-9. [PMID: 25692312 DOI: 10.1148/radiol.15142300] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To investigate cardiac computed tomographic (CT) findings predictive of recurrent stroke in patients with ischemic stroke and determine the incremental risk stratification benefit of cardiac CT findings compared with transesophageal echocardiography (TEE) findings in patients with ischemic stroke. MATERIALS AND METHODS This single-center prospective study protocol was approved by the institutional review boards, and written informed consent was obtained from all patients. Among 548 consecutive patients, 374 patients with ischemic stroke (254 men and 120 women, with a mean age of 63.1 years) who underwent TEE and cardiac CT were prospectively enrolled in this study. TEE and cardiac CT images were assessed for cardioembolic sources, including thrombus, tumor, spontaneous echo contrast, valvular vegetation, atrial septal aneurysm, patent foramen ovale, and aortic plaque. The primary end point was stroke recurrence. Prognostic factors were assessed with Cox univariate and multivariate analysis. The integrated area under the receiver operating characteristic curve was calculated to compare the prognostic abilities of CT and TEE parameters. RESULTS During a median follow-up period of 433 days, there were a total of 28 recurrent stroke events. The TEE parameter of plaque complexity (hazard ratio, 13.512; 95% confidence interval: 3.668, 49.778; P < .001) and CT parameter of plaque complexity (hazard ratio, 32.538; 95% confidence interval: 7.544, 140.347; P < .001) were predictors of recurrent stroke. The time-dependent receiver operating characteristic curve analysis demonstrated no significant differences in prediction of recurrent stroke between TEE and CT parameters (integrated area under the receiver operating characteristic curve, 0.812 vs 0.840, respectively). CONCLUSION Complex aortic plaque evaluated with cardiac CT and TEE was associated with an increased risk of stroke recurrence in patients with ischemic stroke.
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Affiliation(s)
- Kyeho Lee
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Jin Hur
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Sae Rom Hong
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Young Joo Suh
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Dong Jin Im
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Yun Jung Kim
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Yoo Jin Hong
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Hye-Jeong Lee
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Young Jin Kim
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Hye Sun Lee
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Geu-Ru Hong
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
| | - Byoung Wook Choi
- From the Department of Radiology, Research Institute of Radiological Science (K.L., J.H., S.R.H., Y.J.S., D.J.I., Yun Jung Kim, Y.J.H., H.J.L., Young Jin Kim, B.W.C.), and Department of Biostatistics (H.S.L.), Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, 120-752 Seoul, Republic of Korea; and Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, Republic of Korea (G.R.H.)
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Winkler MA, von Herrmann P, Penticuff RH, Majmudar PM, Plaisance BR, Hobbs SB, Brooks MA. A potential role of ECG-gated CT for the diagnosis of pulmonary vein thrombus: an illustrative case report. Clin Imaging 2015; 39:513-5. [PMID: 25631234 DOI: 10.1016/j.clinimag.2014.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 10/27/2014] [Accepted: 11/13/2014] [Indexed: 11/18/2022]
Abstract
The presence of tumor thrombus in patients with lung cancer confers a risk of stroke and other end-organ ischemic events. This case highlights a potential role for electrocardiogram (ECG)-gated computed tomography (CT) in the diagnosis of this pathologic process. In this case, pulmonary vein thrombus was definitively identified by an ECG-CT following discordant results between CT and transthoracic echocardiogram. In addition, this case demonstrates how management decisions are affected by physician accessibility to and familiarity with specific imaging tests.
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Affiliation(s)
- Michael A Winkler
- Department of Radiology, University of Kentucky Chandler Medical Center, Lexington, KY 40536-0293.
| | - Paul von Herrmann
- Department of Radiology, University of Kentucky Chandler Medical Center, Lexington, KY 40536-0293
| | - Ryan H Penticuff
- Department of Radiology, University of Kentucky Chandler Medical Center, Lexington, KY 40536-0293
| | - Palak M Majmudar
- Department of Radiology, University of Kentucky Chandler Medical Center, Lexington, KY 40536-0293
| | - Benjamin R Plaisance
- Department of Radiology, University of Kentucky Chandler Medical Center, Lexington, KY 40536-0293
| | - Stephen B Hobbs
- Department of Radiology, University of Kentucky Chandler Medical Center, Lexington, KY 40536-0293
| | - Michael A Brooks
- Department of Radiology, University of Kentucky Chandler Medical Center, Lexington, KY 40536-0293
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Bang OY, Ovbiagele B, Kim JS. Evaluation of Cryptogenic Stroke With Advanced Diagnostic Techniques. Stroke 2014; 45:1186-94. [DOI: 10.1161/strokeaha.113.003720] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Oh Young Bang
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
| | - Bruce Ovbiagele
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
| | - Jong S. Kim
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.); Department of Neurosciences, Medical University of South Carolina, Charleston (B.O.); and Department of Neurology, Asan Medical Center, University of Ulsan, Seoul, South Korea (J.S.K.)
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Kim SJ, Ryoo S, Kwon S, Park YK, Kim JP, Lee GY, Bang OY. Is Atrial Fibrillation Always a Culprit of Stroke in Patients with Atrial Fibrillation plus Stroke? Cerebrovasc Dis 2013; 36:373-82. [DOI: 10.1159/000355571] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 09/10/2013] [Indexed: 11/19/2022] Open
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Ko JY, Kim YD, Hong YJ, Lee HJ, Hur J, Choi BW, Heo JH, Kim YJ. Lack of association between stroke and left atrial out-pouching structures: results of a case-control study. PLoS One 2013; 8:e76617. [PMID: 24116128 PMCID: PMC3792154 DOI: 10.1371/journal.pone.0076617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 08/27/2013] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose Clinical significance of out-pouching structures of the left atrium (LA) as potential embolic sources remains unclear. We sought to evaluate the association between stroke and LA out-pouching structures. Methods A case-control study was conducted to assess the prevalence of LA out-pouching structures in subjects with and without stroke. Case subjects were 270 stroke patients who had undergone cardiac CT. Control subjects were 270 age- and sex-matched patients without a history of stroke and who had undergone cardiac CT. Presence of LA out-pouching structures was determined by ECG-gated cardiac CT. The location of out-pouching structures was categorized as near Bachmann bundle, anterior, inferoseptal, inferior, and lateral. The prevalence, number and location of out-pouching structures and clinical characteristics were compared between the two groups. Results One hundred sixty eight out-pouching structures were identified in 139 stroke patients (51%), while a total of 169 out-pouching structures were found in 155 control patients (57%) (p=0.1949). The prevalence of LA out-pouching structures with different locations was not significantly different between the stroke group and control group. In the stroke group, the prevalence of out-pouching structures was not significantly different by subtypes of ischemic stroke and the prevalence of LA out-pouching structures was not different between patients with atrial fibrillation (AF) and without AF. Conclusion The left atrial out-pouching structures are commonly seen in a population with and without stroke with similar prevalence. Our study suggests that LA out-pouching structures are not significant risk factors of stroke.
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Affiliation(s)
- Ji Young Ko
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoo Jin Hong
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye-Jeong Lee
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Hur
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Wook Choi
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Division of Cardiovascular Radiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
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Moschini J, Lindenbaum S, Rodríguez Granillo G. Accidente cerebrovascular isquémico cardioembólico: diagnóstico de trombo en la orejuela auricular izquierda con tomografía computada cardíaca. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.neuarg.2013.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kamalian S, Kamalian S, Pomerantz SR, Tanpitukpongse TP, Gupta R, Romero JM, Katz DS. Role of cardiac and extracranial vascular CT in the evaluation/management of cerebral ischemia and stroke. Emerg Radiol 2013; 20:417-28. [DOI: 10.1007/s10140-013-1116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 03/03/2013] [Indexed: 01/09/2023]
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Romero J, Husain SA, Kelesidis I, Sanz J, Medina HM, Garcia MJ. Detection of Left Atrial Appendage Thrombus by Cardiac Computed Tomography in Patients With Atrial Fibrillation. Circ Cardiovasc Imaging 2013; 6:185-94. [DOI: 10.1161/circimaging.112.000153] [Citation(s) in RCA: 239] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jorge Romero
- From the Division of Cardiology and Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., S.A.H., I.K., H.M.M., M.J.G.); and The Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY (J.S.)
| | - Syed Arman Husain
- From the Division of Cardiology and Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., S.A.H., I.K., H.M.M., M.J.G.); and The Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY (J.S.)
| | - Iosif Kelesidis
- From the Division of Cardiology and Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., S.A.H., I.K., H.M.M., M.J.G.); and The Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY (J.S.)
| | - Javier Sanz
- From the Division of Cardiology and Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., S.A.H., I.K., H.M.M., M.J.G.); and The Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY (J.S.)
| | - Hector M. Medina
- From the Division of Cardiology and Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., S.A.H., I.K., H.M.M., M.J.G.); and The Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY (J.S.)
| | - Mario J. Garcia
- From the Division of Cardiology and Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., S.A.H., I.K., H.M.M., M.J.G.); and The Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY (J.S.)
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Sipola P, Hedman M, Onatsu J, Turpeinen A, Halinen M, Jäkälä P, Vanninen R. Computed Tomography and Echocardiography together Reveal More High-Risk Findings than Echocardiography Alone in the Diagnostics of Stroke Etiology. Cerebrovasc Dis 2013; 35:521-30. [DOI: 10.1159/000350734] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/05/2013] [Indexed: 11/19/2022] Open
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Hoey ETD, Mankad K, Al-Chalabi H, Rosa S. The emerging role of cardiovascular MRI for suspected cardioembolic stroke. Clin Radiol 2012; 68:107-16. [PMID: 22939694 DOI: 10.1016/j.crad.2012.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 06/22/2012] [Accepted: 07/05/2012] [Indexed: 10/28/2022]
Abstract
Stroke is a leading cause of morbidity and long-term disability worldwide and is often the result of embolic material from the heart or proximal aorta. These are referred to as cardioembolic sources of stroke. The investigation of patients with suspected cardioembolic stroke has traditionally been the mainstay of echocardiography. Cardiac magnetic resonance imaging (MRI) is a powerful imaging technique that has rapidly evolved over the last decade and is playing an ever increasing role in clinical cardiovascular imaging. This review of the literature aims to furnish the reader with an understanding of the role of cardiac MRI across the spectrum of causes of cardioembolic sources of stroke by providing the reader with an overview of the indications, technical considerations, a proposed imaging algorithm, and capabilities of this technology with selected illustrated examples of disease entities.
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Affiliation(s)
- E T D Hoey
- Department of Radiology, Heart of England NHS Foundation Trust, Birmingham, UK
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Kim SJ, Ryoo S, Hwang J, Noh HJ, Park JH, Choe YH, Bang OY. Characterization of the infarct pattern caused by vulnerable aortic arch atheroma: DWI and multidetector row CT study. Cerebrovasc Dis 2012; 33:549-57. [PMID: 22688060 DOI: 10.1159/000338018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 03/05/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Aortic arch atheroma (AAA) has been accepted as a possible embolic source in patients with ischemic stroke, especially cryptogenic stroke. However, despite its well-known role as a risk factor for stroke, research focused on the mechanism or characteristics of stroke caused by AAA is insufficient. In this study, we aimed to evaluate clinical and radiological characteristics including lesion pattern on DWI in acute stroke patients associated with vulnerable AAA detected by multidetector row computed tomography (MDCT). METHODS From September 2008 through May 2011, patients who presented with acute ischemic stroke and underwent MDCT were found in a prospective stroke registry. Patients without evident stroke etiology were included and classified by presence of vulnerable AAA. Vulnerable AAA was defined as (i) at least 6 mm thick adjacent to the aortic wall; (ii) ulcerated plaque, or (iii) soft plaque. Soft plaque was defined as the presence of clearly visualized area of hypoattenuation (<80 Hounsfield units) suggestive of thrombus. The patients without vulnerable AAA were classified as no/simple AAA group. The characteristics of diffusion-weighted MRI (DWI) lesions were analyzed in terms of the number and size of the lesions, and the involved vascular territories. RESULTS A total of 63 cryptogenic stroke patients were included in this study. Vulnerable AAA was observed in 15 (23.8%) patients. The patients with vulnerable AAA were older than those with no/simple AAA (p = 0.026). DWI analysis revealed that the vulnerable AAA group had a greater chance of having multiple and small lesions in multiple vascular territories that were mainly located in cortical and border-zone regions than the no/simple AAA group. Multiple logistic regression analysis showed that age (odds ratio 1.17; 95% confidence interval 1.02-1.34) and multiple small lesions in multiple vascular territories (odds ratio 33.18; 95% confidence interval 4.26-258.45) were independently associated with vulnerable AAA. CONCLUSION Vulnerable AAA is independently associated with a DWI pattern characterized by multiple small scattered lesions in multiple vascular territories in conjunction with age. It may help determine stroke mechanism quickly and easily, and provide more information about the pathomechanism of vulnerable AAA-related stroke.
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Affiliation(s)
- Suk Jae Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Achenbach S, Barkhausen J, Beer M, Beerbaum P, Dill T, Eichhorn J, Fratz S, Gutberlet M, Hoffmann M, Huber A, Hunold P, Klein C, Krombach G, Kreitner KF, Kühne T, Lotz J, Maintz D, Marholdt H, Merkle N, Messroghli D, Miller S, Paetsch I, Radke P, Steen H, Thiele H, Sarikouch S, Fischbach R. Konsensusempfehlungen der DRG/DGK/DGPK zum Einsatz der Herzbildgebung mit Computertomographie und Magnetresonanztomographie. KARDIOLOGE 2012. [DOI: 10.1007/s12181-012-0417-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Ko Y, Kim WJ, Jang MS, Yang MH, Park JH, Choi SI, Chun EJ, Lee SJ, Han MK, Bae HJ. Is aortic atherothrombotic disease detected using multidetector-row CT associated with an increased risk of early ischemic lesion recurrence after acute ischemic stroke? Stroke 2012; 43:764-9. [PMID: 22282886 DOI: 10.1161/strokeaha.111.632182] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Multidetector-row CT (MDCT) is emerging as a new tool for diagnosing aortic atherothrombotic disease (AAD). We elucidated whether MDCT-detected AAD is associated with an increased risk of early ischemic lesion recurrence on diffusion-weighted MRI after ischemic stroke. METHODS A consecutive series of patients with acute ischemic stroke confirmed using diffusion-weighted MRI who were hospitalized within 48 hours after symptom onset and underwent MDCT were identified in a prospective stroke registry database. AAD on MDCT was defined as the presence of plaque formation that was noncalcified and ≥4 mm thick, ulcerative, or soft and thrombosed (vulnerable) in the proximal aortic arch. Ischemic lesion recurrence on diffusion-weighted MRI was defined as the occurrence of any new lesion separate from the index lesion on follow-up diffusion-weighted MRI performed within 14 days after symptom onset. RESULTS A total of 138 patients was selected. MDCT detected AAD in 24 of 138 (17.4%); ≥4 mm thickness in 17 of 138 (12.3%); ulcerated plaque in 20 of 138 (14.5%); and vulnerable plaque in 16 of 138 (11.6%). With respect to diffusion-weighted MRI lesion recurrence, the crude ORs (95% CIs) were as follows: AAD, 3.56 (1.43-8.89); vulnerable plaque, 3.21 (1.11-9.30); ulcerated plaque, 3.37 (1.27-8.95); and ≥4 mm thickness of the noncalcified plaque, 4.23 (1.11-16.19). These results remained significant after adjustments for potential confounders were made. CONCLUSIONS This study shows that AAD detected by MDCT increases the risk of early ischemic lesion recurrence after acute ischemic stroke, thus supporting the role of MDCT in diagnosing AAD and assessing its contribution to recurrence.
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Affiliation(s)
- Youngchai Ko
- Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Korea
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Kim SJ, Choe YH, Park SJ, Kim GM, Chung CS, Lee KH, Bang OY. Routine cardiac evaluation in patients with ischaemic stroke and absence of known atrial fibrillation or coronary heart disease: transthoracic echocardiography vs. multidetector cardiac computed tomography. Eur J Neurol 2011; 19:317-23. [DOI: 10.1111/j.1468-1331.2011.03505.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Boussel L, Cakmak S, Wintermark M, Nighoghossian N, Loffroy R, Coulon P, Derex L, Cho TH, Douek PC. Ischemic stroke: etiologic work-up with multidetector CT of heart and extra- and intracranial arteries. Radiology 2010; 258:206-12. [PMID: 21062925 DOI: 10.1148/radiol.10100804] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the potential of a single-session multidetector computed tomography (CT) protocol, as compared with established methods, for the etiologic work-up of acute ischemic stroke. MATERIALS AND METHODS Patients found to have recently experienced an ischemic stroke were recruited for this prospective study after institutional review board approval was obtained. Each patient was scheduled for two evaluation strategies: (a) a standard approach involving transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), duplex ultrasonography (US) of the neck vessels, and magnetic resonance (MR) angiography of the neck and brain vessels; and (b) a protocol involving single-session multidetector CT of the heart, neck, and brain vessels. The authors sought to determine the major etiologic factors of stroke, including cardiac sources of embolism and atheroma of the aortic arch and the extra- and intracranial vessels, by using both strategies. RESULTS Multidetector CT, MR imaging, and duplex US were performed in 46 patients, 39 of whom also underwent TEE. The sensitivity and specificity of multidetector CT were 72% (18 of 25 cases) and 95% (20 of 21 cases), respectively, for detection of cardiac sources and 100% (24 of 24 cases) and 91% (20 of 22 cases), respectively, for detection of major arterial atheroma. For the 46 cases of stroke, the final etiologic classifications determined by using the standard combination approach were cardiac sources in 20 (44%) cases, major arterial atheroma in nine (20%), multiple sources in four (9%), and cryptogenic sources in 13 (28%). Multidetector CT facilitated correct etiologic classification for 38 (83%) of the 46 patients. CONCLUSION Multidetector CT is a promising tool for etiologic assessment of ischemic stroke, although the identification of minor cardiac sources with this examination requires the establishment of robust criteria.
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Affiliation(s)
- Loic Boussel
- Department of Radiology, Louis Pradel Hospital, 28 Av Doyen Lepine, 69500 Bron, France.
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Rojas CA, Jaimes CE, El-Sherief AH, Medina HM, Chung JH, Ghoshhajra B, Abbara S. Cardiac CT of non-shunt pathology of the interatrial septum. J Cardiovasc Comput Tomogr 2010; 5:93-100. [PMID: 21130061 DOI: 10.1016/j.jcct.2010.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 09/29/2010] [Accepted: 10/18/2010] [Indexed: 10/18/2022]
Abstract
The development and anatomy of the interatrial septum is complex. With the increasing use of cardiac CT and its precise delineation of the anatomy, it is important for the cardiac imager to become familiar with the normal anatomic structures that compose the interatrial septum and their variants. Furthermore, it is important to recognize pathologic processes occurring in this region other than atrial septal defects and potential imaging pitfalls. This pictorial essay provides a detailed review of these topics with emphasis in CT appearance and related technical aspects.
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Affiliation(s)
- Carlos A Rojas
- Department of Cardiac Imaging, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge Street, Boston, MA 02114, USA.
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Images in cardiology. Atrial fibrillation as a potential risk for ST-segment elevation myocardial infarction. J Am Coll Cardiol 2010; 55:e141. [PMID: 20513591 DOI: 10.1016/j.jacc.2009.09.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Accepted: 09/17/2009] [Indexed: 11/22/2022]
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