Cardiac imaging in ischemic stroke or transient ischemic attack of undetermined cause: Systematic review & meta-analysis

Abstract

Background: Patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause often undergo cardiac imaging in search of a cardioembolic source. As the choice of the most appropriate imaging approach is controversial and therapeutic implications have changed over time, we aimed to identify in patients with "cryptogenic stroke or TIA" the yield of transthoracic or transesophageal echocardiography (TTE or TEE) and cardiac computed tomography (CT). Methods and results: We performed a systematic review and meta-analysis according to the PRISMA guidelines. Included were studies that assessed consecutive patients with ischemic stroke or TIA of undetermined cause to evaluate the yield of TTE, TEE, or cardiac CT for detecting cardioembolic sources. For each type of cardioembolic source the pooled prevalence was calculated. Only six out of 1458 studies fulfilled the inclusion criteria (1022 patients). One study reported the yield of TTE, four of TEE, and one of both TTE and TEE; no study assessed cardiac CT. Mean patient age ranged from 44.3-71.2 years, 49.2-59.7% were male. TTE detected 43 cardioembolic sources in 316 patients (4 (1.3%) major, 39 (12.3%) minor), and TEE 248 in 937 patients (55 (5.9%) major, 193 (20.6%) minor). The most prevalent major cardioembolic source was left atrial appendage thrombus, yet results were heterogeneous among studies. Conclusions: TTE and TEE infrequently detect major cardioembolic sources that require a change of therapy. Findings should be interpreted with caution due to the limited number of studies. A large-sized prospective clinical trial is warranted to support evidence-based decision-making.

Spectral cardiac CT in acute stroke patients

“…Patients with ischemic stroke related to cardio-embolism have a poorer prognosis compared to other stroke subtypes, including higher mortality and increased risk of stroke recurrence 13 . Moreover, in patients with stroke of undetermined etiology, LAA thrombus has been described as the most prevalent among major cardioembolic sources 14 . This study aimed to determine the additional value of spectral reconstructions for the detection of cardio-embolic sources in the setting of a one-stop shop stroke CT protocol including delayed-phase spectral cardiac CT-imaging.…”

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

“…First, we compared cardiac CT with TTE rather than TEE, which has a higher diagnostic yield than TTE. 9,10 We used TTE because it is the recommended first-line screening method for the detection of structural sources of cardioembolism according to the Dutch and European guidelines 2,3 and is part of the stroke workup before classification as ESUS. 1 A large survey among neurologists also found that TEE is infrequently performed in patients with ischemic stroke.…”

“…8 The diagnostic yield of TTE for the detection of high-risk sources of embolism is limited with a yield of 1% for major sources of embolism in patients with cryptogenic stroke. 9 Transoesophageal echocardiography (TEE) has a higher diagnostic accuracy than TTE but is infrequently performed because it is invasive, may require sedation, and carries a small risk of complications 8,10…”

“…8 The diagnostic yield of TTE for the detection of high-risk sources of embolism is limited with a yield of 1% for major sources of embolism in patients with cryptogenic stroke. 9 Transoesophageal echocardiography (TEE) has a higher diagnostic accuracy than TTE but is infrequently performed because it is invasive, may require sedation, and carries a small risk of complications 8,10 Cardiac CT may be a suitable alternative to echocardiography as a first-line screening method for the detection of structural cardioaortic sources of embolism. Cardiac CT can be acquired fast, and data from small-scale retrospective studies suggest that cardiac CT can be incorporated in the acute imaging protocol of stroke patients with a low additional radiation dose.…”

Siêu Âm Tim Ở Bệnh Nhân Đột Quỵ Thiếu Máu Não Được Tái Thông Mạch Não Tại Bệnh Viện Đại Học Y Hà Nội

“…Với 51 bệnh nhân trong nghiên cứu của chúng tôi được siêu âm qua thành ngực thì có 1 bệnh nhân phát hiện huyết khối thất trái với kích thước rất lớn 18mm chiếm 1,96% (Nghiên cứu của Gerlinde van der Maten là 0,97%, theo Margaret Morres là 1,94%). 5 Kết quả của chúng tôi khá tương đồng so với những nghiên cứu này. Tuy nhiên, với các nghiên cứu của nước ngoài, 1 số lượng bệnh nhân nhất định sẽ được tiến hành siêu âm tim qua thực quản để đánh giá khi có nghi ngờ và một tỷ lệ tương đối huyết khối buồng tim đã được phát hiện (Muhammad K Ahmed là 4,4%, theo Gerlinde van der Maten lên tới 18,04% theo Liqun Zhang năm 2012 là 6,67%).…”