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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

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 CCTASecondary21%
Overall detection of intra-cardiac thrombus in ESUS populationSecondary8.2%

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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