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Cardiac CT vs TTE

Diagnostic Yield of ECG-Gated Cardiac CT in the Acute Phase of Ischemic Stroke vs Transthoracic Echocardiography

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Year of Publication: 2022

Authors: Leon A. Rinkel, MD, Valeria Guglielmi, ..., and Jonathan M. Coutinho

Journal: Neurology

Citation: Neurology® 2022;99:e1456-e1464. doi:10.1212/WNL.0000000000200995

Link: https://n.neurology.org/content/99/13/e1456

Clinical Question

Does cardiac computed tomography (CT), acquired during the initial stroke imaging protocol, have a higher yield for detecting high-risk cardioaortic sources of embolism than transthoracic echocardiography (TTE) in patients with ischemic stroke?

Bottom Line

Cardiac CT has a significantly higher diagnostic yield for detecting high-risk cardioaortic sources of embolism in patients with acute ischemic stroke compared to transthoracic echocardiography (TTE), especially for left atrial appendage thrombi. It can be a promising first-line screening method in the acute phase of ischemic stroke.

Major Points

  • A total of 300 patients with ischemic stroke were included; 198 underwent cardiac CT and 102 received TTE as initial cardiac workup.
  • Detection rate of high-risk cardioaortic sources of embolism: 12.6% (25/198) with cardiac CT vs 5.9% (6/102) with TTE (adjusted risk ratio [aRR], 2.11; 95% CI, 0.95-4.68; P=0.06).
  • Cardiac CT detected left atrial appendage thrombi in 10 patients (5.1%) vs 0 patients with TTE (P=0.01).
  • Cardiac CT detected aortic arch atheroma in 10 patients (5.1%) vs 0 patients with TTE (P=0.01).
  • Cardiac CT detected more sources of embolism in ESUS patients compared to TTE (13.8% vs 4.2%, aRR 3.32, 95% CI 0.76-14.47, P=0.11).
  • Overall, cardiac CT led to a change in management in 9 patients (4.5%) compared to TTE (2 patients, 2.0%) (aRR 2.05, 95% CI 0.40-10.45, P=0.38).

Design

Study Type: Prospective, single-center, observational cohort study

Randomization:

Blinding: Blinded re-evaluation of cardiac CT and echocardiography by an independent cardiologist and neuroradiologist, unaware of patients' clinical data.

Enrollment Period: September 2017 to June 2020

Follow-up Duration: Not specified; focus on diagnostic yield at presentation.

Centers: 1

Countries: Netherlands

Sample Size: 300

Analysis: Continuous variables as mean±SD or median (IQR), categorical as numbers and percentages. Fisher's exact test for detection rates. Multivariable logistic regression to compare yields (adjusted for age, sex, and history of stroke). Sensitivity analyses using different definitions for high-risk sources and including specific subgroups. Statistical analysis using R.

Inclusion Criteria

  • Patients aged ≥18 years admitted with acute ischemic stroke.
  • Patients who underwent acute phase brain imaging (CT/MRI) and ECG-gated cardiac CT and/or TTE as part of their diagnostic workup.

Exclusion Criteria

  • Patients with known high-risk cardioembolic sources (e.g., atrial fibrillation, mechanical heart valve, severe valvular heart disease, endocarditis).
  • Patients with other identified stroke etiologies.

Outcomes

OutcomeTypeControlInterventionHR / OR / RRP-value
Detection rate of high-risk cardioaortic sources of embolism by cardiac CT vs. TTESecondary5.9% (6/102)12.6% (25/198)2.110.06
Detection of left atrial appendage thrombus by cardiac CT vs. TTESecondary0 (0%)10 (5.1%)0.01
Detection of aortic arch atheroma by cardiac CT vs. TTESecondary0 (0%)10 (5.1%)0.01
Cardiac CT changed management vs. TTESecondary2 (2.0%)9 (4.5%)2.050.38
Detection of sources in ESUS patients by Cardiac CT vs. TTESecondary4.2%13.8%3.320.11

Criticisms

  • This is a single-center, observational cohort study, which is prone to selection bias and confounding, limiting the ability to establish causality.
  • Patients did not undergo both cardiac CT and TTE systematically, and the decision to perform either or both was not randomized, introducing potential for bias.
  • The study did not assess the long-term clinical outcomes or recurrence rates of stroke based on the diagnostic findings.
  • The study included a relatively small sample size, which limits the power to detect smaller, but clinically relevant, differences.
  • The study did not provide detailed information on the specific types or characteristics of high-risk cardioaortic sources beyond the initial detection rates.

Subgroup Analysis

Subgroup analysis was performed for ESUS patients compared to TIA/Ischemic Stroke of Determined Source, showing higher diagnostic yield of cardiac CT for ESUS patients. Sensitivity analyses using different definitions for high-risk sources were also conducted.

Funding

Dutch Heart Foundation (grant 2018T054) and an unrestricted research grant from Boehringer Ingelheim.

Based on: Cardiac CT vs TTE (Neurology, 2022)

Authors: Leon A. Rinkel, MD, Valeria Guglielmi, ..., and Jonathan M. Coutinho

Citation: Neurology® 2022;99:e1456-e1464. doi:10.1212/WNL.0000000000200995

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