Cardiac CT a promising tool to detect embolic source in ischemic stroke

Cardiac computed tomography angiography appears to be a promising tool for the detection of intra-cardiac thrombi along with standard care for patients having Embolic stroke of undetermined source. The study was published in the European Stoke Journal. 

Embolic stroke of the undetermined source is an evolving stroke subtype. It poses a great clinical challenge for a secondary prevention strategy. Cardiac imaging is the foundation of embolic stroke workup for diagnosing high-risk cardio-embolic sources. Cardiac computed tomography angiography (CCTA) is a developing imaging technique having a high diagnostic performance for detecting intra-cardiac thrombus. There is uncertainty on the result of using CCTA along with standard care in ESUS workup. So, researchers conducted a study to assess the utility of CCTA in detecting intra-cardiac thrombi in the routine ESUS workup. 

A retrospective observational analysis of ESUS cases that are managed in the vascular neurology unit between 2019 and 2021 was done. Within this ESUS registry, consecutive patients undergoing CCTA were included and carefully analyzed. 

Results:

• 1066 Ischemic stroke (IS) cases were treated and evaluated.
• 266/1066 (25%) met ESUS criteria and 129/266 (48%) underwent CCTA.
• Intra-cardiac thrombus was detected by CCTA in 22/129 patients. Out of which, left ventricular thrombus (LVT) in 13 (10.1%) patients, left atrial appendage (LAA) thrombus in 8 (6.2%) patients, and left atrial (LA) thrombus in 1 (0.8%) patient.
• Only 5/22 (23%) of these thrombi were suspected, but could not be confirmed, in trans-thoracic echocardiogram (TTE).
• Among CCTA-undergoing patients, 27/129 wereindicatecation for commencing anticoagulation (AC) treatment, rather than anti-platelets.
• In favor of CCTA implementation, 22/266 patients within the entire ESUS cohort were diagnosed with intra-cardiac thrombus, otherwise missed.

Thus, CCTA proves to be a promising tool for detecting intra-cardiac thrombi in addition to standard care in ESUS patients and can thus alter the secondary prevention strategy in a considerable proportion of patients.

Further reading: https://doi.org/10.1177/23969873221099692 

Barnea R, Agmon IN, Shafir G, Peretz S, Mendel R, Naftali J, Shiyovich A, Kornowski R, Auriel E, Hamdan A; Cardiac CT for Undetermined Source of Embolic Stroke (CaCTUSES) Working Group. Cardiac CT for intra-cardiac thrombus detection in an embolic stroke of undetermined source (ESUS). Eur Stroke J. 2022 Sep;7(3):212-220.