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CaCTUSES

Cardiac CT for intra-cardiac thrombus detection in embolic stroke of undetermined source (ESUS)

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Year of Publication: 2022

Authors: Barnea R, Nardi Agmon I, Shafir G, ..., Hamdan A

Journal: European Stroke Journal

Citation: Barnea R, et al. Eur Stroke J. 2022;7(3):212–220.

Link: https://doi.org/10.1177/23969873221099692

Clinical Question

Does cardiac CT angiography (CCTA) improve the detection of intra-cardiac thrombus in ESUS patients and affect secondary prevention strategy?

Bottom Line

In ESUS patients, cardiac CT detected intra-cardiac thrombus in 17% (22/129) — LV thrombus 10.1%, LAA thrombus 6.2%. Standard TTE missed 77% of these. CCTA changed management in 21% (27/129) from antiplatelet to anticoagulant. At population level, 8.2% of all ESUS patients (22/266) had thrombi detected only by CCTA. Predictors: IHD (59% vs 28%), CHF (40% vs 6%), reduced EF (mean 46% vs 57%), apical hypokinesia (59% vs 12%).

Major Points

  • CCTA detected thrombus in 17% (22/129) of ESUS patients: LVT 10.1%, LAA 6.2%, LA body 0.8%.
  • TTE missed 77% (17/22) of thrombi — only 5/22 even suspected on TTE.
  • Changed management in 21% (27/129) — antiplatelet to anticoagulant (thrombus n=22, PE n=7).
  • Population impact: 8.2% (22/266) of all ESUS patients had thrombi detectable only by CCTA.
  • Predictors: IHD (59% vs 28%; P=0.01), CHF (40% vs 6%; P<0.0001), reduced EF (46% vs 57%; P<0.0001), apical hypokinesia (59% vs 12%; P<0.0001).
  • All 13 LVTs in apex with wall motion abnormality. 2 had previously unknown prior MI (new dx on CCTA).
  • CCTA also found PE in 7 patients and subclinical leaflet thrombosis in 2.
  • Retrospective, single-center (Beilinson Hospital, Israel), 129 CCTA + 57 TEE patients.
  • TEE preferred in younger (<60yr) PFO candidates; CCTA preferred in older cardiovascular-risk patients.
  • Supports CCTA in routine ESUS workup, especially with apical hypokinesia, reduced EF, IHD, or CHF.

Design

Study Type: Retrospective observational study

Randomization:

Blinding:

Enrollment Period: April 2019 to October 2021

Centers: 1

Countries: Israel

Sample Size: 266

Analysis: Descriptive and comparative statistical analysis using SPSS

Inclusion Criteria

  • Non-lacunar ischemic stroke
  • No AF on ECG or telemetry (>20h)
  • No significant arterial stenosis (>50%)
  • No identifiable embolic source on transthoracic echo

Exclusion Criteria

  • TIA (transient ischemic attack)
  • Renal dysfunction (for contrast)
  • Inability to cooperate with CT (e.g., aphasia, instability)
  • Preference for TEE when evaluating valvular sources or PFO

Baseline Characteristics

CharacteristicComorbiditiesQualifying Event
Hypertension76
Diabetes41
Prior Stroke32
Smoker22

Arms

FieldCCTA Group
InterventionCardiac CT angiography performed in ESUS patients
DurationSingle imaging during hospitalization

Outcomes

OutcomeTypeControlInterventionHR / OR / RRP-value
Detection of intra-cardiac thrombus on CCTAPrimary17%
Patients requiring anticoagulation based on CCTA | 95% CI: 14%–28%Secondary21%
Overall detection of intra-cardiac thrombus in ESUS population | 95% CI: 4.9%–11.5%Secondary8.2%
Observational studyAdverseRetrospective observational study of cardiac CT in ESUS - no safety/AE data reported

Subgroup Analysis

CCTA more commonly detected thrombi in patients with CHF or IHD. LVT was associated with apical hypokinesia on echo.

Criticisms

  • Retrospective and single-center design
  • No comparison between CCTA and TEE in the same patients
  • No long-term outcomes reported
  • Selection bias due to imaging modality availability and patient stability

Funding

None reported

Based on: CaCTUSES (European Stroke Journal, 2022)

Authors: Barnea R, Nardi Agmon I, Shafir G, ..., Hamdan A

Citation: Barnea R, et al. Eur Stroke J. 2022;7(3):212–220.

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