CT angiography vs echocardiography for detection of cardiac thrombi in ischemic stroke: a systematic review and meta-analysis

Abstract

Background and purpose Cardiac thrombi are an important cause of embolic stroke. We studied the diagnostic yield and diagnostic accuracy of cardiac CT angiography (CTA) compared to echocardiography for detection of cardiac thrombi in ischemic stroke patients. Methods We performed a systematic review and meta-analysis of the literature on cardiac CTA versus echocardiography for detection of cardiac thrombi in ischemic stroke patients. We included studies (N ≥ 20) in which both cardiac CTA (index test) and echocardiography (reference test) were performed and data on cardiac thrombi were reported. Results were stratified for type of echocardiography: transesophageal (TEE) vs transthoracic (TTE). Results Out of 1530 studies, 14 were included (all single center cohort studies), with data on 1568 patients. Mean age varied between 52 and 69 years per study and 66% were men. Reported time intervals ranged from 0 to 21 days between stroke and first test, and from 0 to 199 days between tests. In ten studies that compared CTA to TEE, CTA detected cardiac thrombi in 87/1385 (6.3%) patients versus 68/1385 (4.9%) on TEE (p < 0.001). In four studies comparing CTA to TTE, CTA detected thrombi in 23/183 (12.5%) patients versus 12/183 (6.6%) on TTE (p = 0.010). Pooled sensitivity and specificity of CTA versus TEE were 86.0% (95% CI 65.6-95.2) and 97.4% (95% CI 95.0-98.7), respectively. Conclusions CTA may be a promising alternative to echocardiography for detection of cardiac thrombi in patients with ischemic stroke, especially now that CTA is standard care for patient selection for endovascular treatment. However, studies were too heterogeneous and of insufficient methodological quality to draw firm conclusions. Large, prospective studies on this topic are warranted.

Mind the Heart: Electrocardiography-gated cardiac computed tomography-angiography in acute ischaemic stroke—rationale and study design

“…Performing TTE at this time is quicker than typically reported in other studies in stroke patients. 5,16,32 As our primary outcome we chose the diagnostic yield of cardiac CTA versus TTE, and not diagnostic accuracy of CTA versus TTE. We did so because we believe that due to the lack of a true gold standard for many cardio-aortic sources of embolism, presenting results in terms of sensitivity/specificity does not necessarily reflect the truth.…”

“…Performing TTE at this time is quicker than typically reported in other studies in stroke patients. 5 , 16 , 32 …”

“…We did so because we believe that due to the lack of a true gold standard for many cardio-aortic sources of embolism, presenting results in terms of sensitivity/specificity does not necessarily reflect the truth. 16 Especially in cases in which TTE is more likely to present false-negative results, diagnostic accuracy does not do justice to the potential value of CTA. 16 Diagnostic yield takes into account certain unique, non-overlapping qualities of both CTA and TTE.…”

“…Studies suggest that cardiac CT-angiography (CTA) may be a promising alternative to echocardiography for the detection of cardiac thrombi and other cardio-aortic sources of embolism. 13 – 16 Now that CTA of the cervical and intracranial arteries is routinely done to determine eligibility for endovascular treatment (EVT), and additional radiation associated with cardiac CTA is low with modern CT scanners, 17 cardiac and complete aortic arch CTA could relatively easily be included in the acute phase imaging protocol. This could result in faster diagnosis and improved treatment of cardioembolic stroke and reduce the number of patients with ESUS.…”

CT Angiography of the Heart and Aorta in TIA and Ischaemic Stroke: Cardioembolic Risk Sources and Clinical Implications

“…Early CTA screening could carry therapeutic implications by identifying a possible embolic source. Previous studies showed that implementation of CTA of the heart and aorta is a feasible alternative to TEE for identification of CE sources, 12 however, these studies either included patients with a high probability for having CE sources (e. g. suspected embolic stroke or AF), 4,10,13À17 or did not include patients with suspected TIA. 18À20 The objective of this study was therefore to investigate the yield and the therapeutic implications of CTA of the heart and aorta in patients presenting with TIA or IS without a specific high probability for CE sources.…”