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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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Kee TP, Venkatanarasimha N, Mohideen SMH, Chan LL, Gogna A, Schaefer PW, Chia GS, Choi YS, Chen RC. A Tale of Two Organ Systems: Imaging review of diseases affecting the thoracic and neurological systems. Part 1. Curr Probl Diagn Radiol 2021; 51:589-598. [PMID: 34304949 DOI: 10.1067/j.cpradiol.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 05/01/2021] [Accepted: 06/16/2021] [Indexed: 11/22/2022]
Abstract
In an era of rapidly expanding knowledge and sub-specialization, it is becoming increasingly common to focus on one organ system. However, the human body is intimately linked, and disease processes affecting one region of the body not uncommonly affect the other organ systems as well. Understanding diseases from a macroscopic perspective, rather than a narrow vantage point, enables efficient and accurate diagnosis. This tenet holds true for diseases affecting both the thoracic and neurological systems; in isolation, the radiologic appearance of disease in one organ system may be nonspecific, but viewing the pathophysiologic process in both organ systems may markedly narrow the differential considerations, and potentially lead to a definitive diagnosis. In this article, we discuss a variety of disease entities known to affect both the thoracic and neurological systems, either manifesting simultaneously or at different periods of time. Some of these conditions may show neither thoracic nor neurological manifestations. These diseases have been systematically classified into infectious, immune-mediated / inflammatory, vascular, syndromic / hereditary and neoplastic disorders. The underlying pathophysiological mechanisms linking both regions and radiologic appearances in both organ systems are discussed. When appropriate, brief clinical and diagnostic information is provided. Ultimately, accurate diagnosis will lead to expedited triage and prompt institution of potentially life-saving treatment for these groups of complex disorders.
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Affiliation(s)
- Tze Phei Kee
- Singapore General Hospital, Singapore 169608; National Neuroscience Institute, Singapore 308433.
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Zafar A, Kalra DK. Vanished into thin air - Morgagni hernia producing echo artifact and diagnosed by cardiac CT. J Cardiovasc Comput Tomogr 2020; 14:e31-e32. [DOI: 10.1016/j.jcct.2018.11.007] [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: 10/29/2018] [Revised: 11/21/2018] [Accepted: 11/25/2018] [Indexed: 11/29/2022]
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Yoo SM, Jang S, Kim JA, Chun EJ. Troponin-Positive Non-Obstructive Coronary Arteries and Myocardial Infarction with Non-Obstructive Coronary Arteries: Definition, Etiologies, and Role of CT and MR Imaging. Korean J Radiol 2020; 21:1305-1316. [PMID: 32783414 PMCID: PMC7689141 DOI: 10.3348/kjr.2020.0064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/28/2020] [Accepted: 04/22/2020] [Indexed: 12/12/2022] Open
Abstract
In approximately 10% of patients with acute myocardial infarction (MI), angiography does not reveal an obstructive coronary stenosis. This is known as myocardial infarction with non-obstructive coronary arteries (MINOCA), which has complex and multifactorial causes. However, this term can be confusing and open to dual interpretation, because MINOCA is also used to describe patients with acute myocardial injury caused by ischemia-related myocardial necrosis. Therefore, with regards to this specific context of MINOCA, the generic term for MINOCA should be replaced with troponin-positive with non-obstructive coronary arteries (TpNOCA). The causes of TpNOCA can be subcategorized into epicardial coronary (causes of MINOCA), myocardial, and extracardiac disorders. Cardiac magnetic resonance imaging can confirm MI and differentiate various myocardial causes, while cardiac computed tomography is useful to diagnose the extracardiac causes.
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Affiliation(s)
- Seung Min Yoo
- Department of Radiology, CHA University Bundang Medical Center, Seongnam, Korea
| | - Sowon Jang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong A Kim
- Department of Radiology, Yonsei University Yongin Severance Hospital, Yongin, Korea
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, 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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Saric M, Armour AC, Arnaout MS, Chaudhry FA, Grimm RA, Kronzon I, Landeck BF, Maganti K, Michelena HI, Tolstrup K. Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism. J Am Soc Echocardiogr 2016; 29:1-42. [PMID: 26765302 DOI: 10.1016/j.echo.2015.09.011] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.
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Affiliation(s)
- Muhamed Saric
- New York University Langone Medical Center, New York, New York
| | | | - M Samir Arnaout
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Farooq A Chaudhry
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Richard A Grimm
- Learner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | - Kirsten Tolstrup
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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You JY, Chun EJ, Choi SI, Joe E, Lee W, Kang JW, Seo MK, Yoon YE, Oh IY, Kim E, Lim TH. Clinical significance of incidentally detected aneurysms of the membranous ventricular septum in adults by multidetector computed tomography. Am J Cardiol 2015; 115:354-9. [PMID: 25491239 DOI: 10.1016/j.amjcard.2014.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 11/01/2014] [Accepted: 11/01/2014] [Indexed: 11/15/2022]
Abstract
Although the clinical relevance of aneurysm of the membranous ventricular septum (AMVS) in adults is unclear, the frequency of AMVS detection has been increased because cardiac multidetector computed tomography has been widely adopted for the evaluation of coronary artery disease. Therefore, we aimed to assess the clinical significance of AMVS in a longitudinal study. In 30,120 adults with suspected coronary artery disease who underwent cardiac multidetector computed tomography in 3 hospitals, 52 patients with AMVS were retrospectively selected. We evaluated the clinical symptoms and electrocardiographic abnormalities (cross-sectional study) and the prevalence of embolic stroke (observational study) during a median 40-month (range 6 to 74 months) observation period. For the assessment of embolic stroke, we excluded 9 patients with other explainable embolic sources. Conduction abnormalities were noted in 13 of 52 adults (25%) with AMVS on electrocardiography and embolic stroke occurred in 6 of 43 patients (14%). The mean age and the prevalence of hypertension were significantly higher in the embolic stroke group than in the event-free group (p <0.05). Thrombi were detected in the 11.6% of AMVS, which was significantly related with embolic stroke (p <0.05). The size and morphology did not change in 15 patients with serial follow-up images. In conclusion, our study suggests that AMVS in adults should not be ignored because AMVS may be related to conduction abnormality or embolic stroke, and it does not spontaneously resolve or diminish in size.
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Affiliation(s)
- Ja Yeon You
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggido, Korea
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggido, Korea.
| | - Sang Il Choi
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggido, Korea
| | - Eugene Joe
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggido, Korea
| | - Whal Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Joon-Won Kang
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Myung-Ki Seo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yeonyee E Yoon
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggido, Korea
| | - Il-Young Oh
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggido, Korea
| | - Eunhee Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggido, Korea
| | - Tae-Hwan Lim
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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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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Hong YJ, Hur J, Kim YJ, Lee HJ, Nam JE, Kim HY, Choe KO, Choi BW. The usefulness of delayed contrast-enhanced cardiovascular magnetic resonance imaging in differentiating cardiac tumors from thrombi in stroke patients. Int J Cardiovasc Imaging 2011; 27 Suppl 1:89-95. [DOI: 10.1007/s10554-011-9961-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 10/07/2011] [Indexed: 10/17/2022]
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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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