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October 04, 2022; 99 (14) Research Article

Diagnostic Yield of ECG-Gated Cardiac CT in theAcute Phase of Ischemic Stroke vsTransthoracic Echocardiography

Leon A. Rinkel, Valeria Guglielmi, View ORCID ProfileChiel F.P. Beemsterboer, Nina-Suzanne Groeneveld, Nick H.J. Lobé, S. Matthijs Boekholdt, Berto J. Bouma, Fenna F. Muller, Ludo F.M. Beenen, View ORCID ProfileHenk A. Marquering, View ORCID ProfileCharles B.L.M. Majoie, View ORCID ProfileYvo B.W.M. Roos, Adrienne van Randen, View ORCID ProfileR. Nils Planken, View ORCID ProfileJonathan M. Coutinho
First published August 2, 2022, DOI: https://doi.org/10.1212/WNL.0000000000200995
Leon A. Rinkel
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Valeria Guglielmi
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Chiel F.P. Beemsterboer
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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  • ORCID record for Chiel F.P. Beemsterboer
Nina-Suzanne Groeneveld
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Nick H.J. Lobé
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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S. Matthijs Boekholdt
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Berto J. Bouma
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Fenna F. Muller
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Ludo F.M. Beenen
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Henk A. Marquering
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Charles B.L.M. Majoie
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Yvo B.W.M. Roos
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Adrienne van Randen
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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R. Nils Planken
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Jonathan M. Coutinho
From the Departments of Neurology (L.A.R., V.G., C.F.P.B., N.-S.G., F.F.M., Y.B.W.M.R., J.M.C.), Radiology and Nuclear Medicine (N.H.J.L., L.F.M.B., H.A.M., C.B.L.M.M., A.v.R., R.N.P.), Cardiology (S.M.B., B.J.B.), and Biomedical Engineering and Physics (H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
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Citation
Diagnostic Yield of ECG-Gated Cardiac CT in theAcute Phase of Ischemic Stroke vsTransthoracic Echocardiography
Leon A. Rinkel, Valeria Guglielmi, Chiel F.P. Beemsterboer, Nina-Suzanne Groeneveld, Nick H.J. Lobé, S. Matthijs Boekholdt, Berto J. Bouma, Fenna F. Muller, Ludo F.M. Beenen, Henk A. Marquering, Charles B.L.M. Majoie, Yvo B.W.M. Roos, Adrienne van Randen, R. Nils Planken, Jonathan M. Coutinho
Neurology Oct 2022, 99 (14) e1456-e1464; DOI: 10.1212/WNL.0000000000200995

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Abstract

Background and Objectives Guidelines recommend echocardiography to screen for structural sources of cardioembolism in patients with ischemic stroke. Cardiac CT is a promising alternative as a first-line screening method. We aimed to determine whether cardiac CT, acquired during the initial stroke imaging protocol, has a higher yield for detecting high-risk cardioaortic sources of embolism than transthoracic echocardiography (TTE).

Methods We performed a prospective, single-center, observational cohort study and included consecutive adult patients with acute ischemic stroke who underwent ECG-gated cardiac CT during the initial stroke imaging protocol. Patients also underwent the routine stroke workup, including TTE. The main outcome was the proportion of patients with a predefined high-risk cardioaortic source of embolism on cardiac CT vs TTE in patients undergoing both investigations.

Results Between May 2018 and November 2020, 774 patients with a suspected ischemic stroke underwent hyperacute cardiac CT. We excluded 228 patients with a diagnosis other than ischemic stroke and 94 because they did not provide informed consent. Therefore, 452 patients (59.3% male, median age 72) were included. The median additional scan time of cardiac CT was 6 (interquartile range 5–7) minutes with poor scan quality in only 3%. In total, 350 of the 452 patients (77.4%) underwent TTE, 99 of whom were performed in an outpatient setting. Reasons for not undergoing TTE were death (33, 7.3%) and TTE being too burdensome to perform in the outpatient setting (69, 15.3%). A high-risk cardioaortic source of embolism was detected in 40 of the 350 patients (11.4%) on CT, compared with 17 of the 350 (4.9%) on TTE (odds ratio 5.60, 95% CI 2.28–16.33). Cardiac thrombus was the most frequent finding (7.1% vs 0.6%). The diagnostic yield of cardiac CT in the full study population was 55 of the 452 (12.2%). Among the 175 patients with cryptogenic stroke after the routine workup, cardiac CT identified a cause of the stroke in 11 (6.3%).

Discussion Cardiac CT acquired in the acute phase of ischemic stroke is technically feasible and has a superior diagnostic yield compared with TTE for the detection of high-risk sources of embolism. Cardiac CT may be considered as an alternative to TTE to screen for cardioembolism.

Glossary

ESUS=
embolic stroke of undetermined source;
EVT=
endovascular treatment;
HU=
Hounsfield unit;
IQR=
interquartile range;
IVT=
IV thrombolysis;
LVEF=
left ventricular ejection fraction;
OR=
odds ratio;
PFO=
patent foramen ovale;
TEE=
transoesophageal echocardiography;
TTE=
transthoracic echocardiography

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • ↵* These authors contributed equally to this work as co-first authors.

  • ↵† These authors contributed equally to this work as co-senior authors.

  • Submitted and externally peer reviewed. The handling editor was Brad Worrall, MD, MSc, FAAN.

  • Editorial, page 595

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  • Received December 23, 2021.
  • Accepted in final form June 8, 2022.
  • © 2022 American Academy of Neurology
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