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Kotadia ID, O'Dowling R, Aboagye A, Crawley RJ, Bodagh N, Gharaviri A, O'Hare D, Solis‐Lemus JA, Roney CH, Sim I, Ramsey D, Newby D, Chiribiri A, Plein S, Sztriha L, Scott P, Masci P, Harrison J, Williams MC, Birns J, Somerville P, Bhalla A, Niederer S, O'Neill M, Williams SE. High Prevalence of New Clinically Significant Findings in Patients With Embolic Stroke of Unknown Source Evaluated by Cardiac Magnetic Resonance Imaging. J Am Heart Assoc 2024; 13:e031489. [PMID: 38240222 PMCID: PMC11056130 DOI: 10.1161/jaha.123.031489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Embolic stroke of unknown source (ESUS) accounts for 1 in 6 ischemic strokes. Current guidelines do not recommend routine cardiac magnetic resonance (CMR) imaging in ESUS, and beyond the identification of cardioembolic sources, there are no data assessing new clinical findings from CMR in ESUS. This study aimed to assess the prevalence of new cardiac and noncardiac findings and to determine their impact on clinical care in patients with ESUS. METHODS AND RESULTS In this prospective, multicenter, observational study, CMR imaging was performed within 3 months of ESUS. All scans were reported according to standard clinical practice. A new clinical finding was defined as one not previously identified through prior clinical evaluation. A clinically significant finding was defined as one resulting in further investigation, follow-up, or treatment. A change in patient care was defined as initiation of medical, interventional, surgical, or palliative care. From 102 patients recruited, 96 underwent CMR imaging. One or more new clinical findings were observed in 59 patients (61%). New findings were clinically significant in 48 (81%) of these patients. Of 40 patients with a new clinically significant cardiac finding, 21 (53%) experienced a change in care (medical therapy, n=15; interventional/surgical procedure, n=6). In 12 patients with a new clinically significant extracardiac finding, 6 (50%) experienced a change in care (medical therapy, n=4; palliative care, n=2). CONCLUSIONS CMR imaging identifies new clinically significant cardiac and noncardiac findings in half of patients with recent ESUS. Advanced cardiovascular screening should be considered in patients with ESUS. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04555538.
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Affiliation(s)
- Irum D. Kotadia
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Robert O'Dowling
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Akosua Aboagye
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Richard J. Crawley
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Neil Bodagh
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Ali Gharaviri
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
| | - Daniel O'Hare
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Jose Alonso Solis‐Lemus
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Caroline H. Roney
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Iain Sim
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | | | - David Newby
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Sven Plein
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | | | - Paul Scott
- King’s College HospitalLondonUnited Kingdom
| | - Pier‐Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | | | - Michelle C. Williams
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
| | - Jonathan Birns
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Peter Somerville
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Ajay Bhalla
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
- Guy’s and St Thomas’ National Health Service Foundation TrustLondonUnited Kingdom
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King’s College LondonLondonUnited Kingdom
- Centre for Cardiovascular Science, The University of EdinburghEdinburghUnited Kingdom
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2
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Molina-Fuentes MF, Neumann R, Behringer W, Franz M, Schulze PC, Witte OW, Günther A, Klingner C, Lehmkuhl L, Steiniger B, Teichgräber U, Rod JE, Mayer TE. Feasibility of the Big 5-Jena eCS Protocol : First Experience Implementing a New Extended CT Protocol in the Initial Diagnostics of Ischemic Stroke. Clin Neuroradiol 2021; 31:901-909. [PMID: 34379134 PMCID: PMC8356684 DOI: 10.1007/s00062-021-01058-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/18/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE The most common protocols in the initial diagnostic of acute ischemic stroke do not assess cardiogenic or aortic causes of embolism. These are usually evaluated later by transthoracic (TTE) or transesophageal (TEE) echocardiography. This study aimed to evaluate the feasibility of a diagnostic tool for thoracic cardiovascular thrombi according to the first experience with a new extended cardio-stroke protocol (Big 5-Jena eCS protocol) in acute stroke patients. METHODS Retrospective analyses of the tomography scans database of the Jena University Hospital were performed. We included a total of 67 patients in the feasibility analyses, based on the evaluation of three outcomes. RESULTS Primary outcome: the Big 5-Jena eCS protocol was able to detect thoracic cardiovascular thrombi in a total of 20 patients in different locations including the arch of the aorta, the aortic valve, the left atrium, the left atrial appendage, the left ventricle, and the pulmonary arteries. Secondary outcome: implementating the protocol did not result in a significant elevation of the radiation exposure compared to traditional protocols. Tertiary outcome: the new protocol identified seven cases that were considered negative by echocardiography. CONCLUSION The implementation of an extended cardio-stroke protocol is feasible, no significantly time-consuming, acquiring assessable imaging, and maintaining radiation exposure acceptable. The Big 5-Jena eCS protocol was also able to detect some thrombi not reported by TTE or TEE; however, due to our data's explorative character, a conclusive comparison with cardiac ultrasound is not possible. A prospective pilot study and clinical trials should be conducted to assess the diagnostic accuracy of this protocol compared to echocardiography and determine the potential impact on diagnostic and treatment decisions.
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Affiliation(s)
- Moisés F Molina-Fuentes
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany. .,Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.
| | - Rotraud Neumann
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Wilhelm Behringer
- Emergency Department, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Albrecht Günther
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Carsten Klingner
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Lukas Lehmkuhl
- Clinic for Radiology, Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Beatrice Steiniger
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Ulf Teichgräber
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - J E Rod
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Thomas E Mayer
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
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Austein F, Eden M, Both M, Salehi Ravesh M, Jansen O, Langguth P. In Reply: Practicability and Diagnostic Yield of One-Stop Stroke CT with Delayed-Phase Cardiac CT in Detecting Major Cardioembolic Sources of Acute Ischemic Stroke. Clin Neuroradiol 2021; 31:923-924. [PMID: 34228139 PMCID: PMC8648679 DOI: 10.1007/s00062-021-01045-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Friederike Austein
- Department of Neuroradiological Intervention and Diagnostics, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
| | - Matthias Eden
- Department of Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Marcus Both
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Mona Salehi Ravesh
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Olav Jansen
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Patrick Langguth
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1038] [Impact Index Per Article: 346.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Schnabel RB, Camen S, Knebel F, Hagendorff A, Bavendiek U, Böhm M, Doehner W, Endres M, Gröschel K, Goette A, Huttner HB, Jensen C, Kirchhof P, Korosoglou G, Laufs U, Liman J, Morbach C, Nabavi DG, Neumann-Haefelin T, Pfeilschifter W, Poli S, Rizos T, Rolf A, Röther J, Schäbitz WR, Steiner T, Thomalla G, Wachter R, Haeusler KG. Expert opinion paper on cardiac imaging after ischemic stroke. Clin Res Cardiol 2021; 110:938-958. [PMID: 34143285 PMCID: PMC8238761 DOI: 10.1007/s00392-021-01834-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/01/2021] [Indexed: 12/19/2022]
Abstract
This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
| | - Stephan Camen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Knebel
- Department of Cardiology and Angiology, University of Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Michael Böhm
- Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg (Saar) , Germany
| | - Wolfram Doehner
- Berlin Institute of Health, Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany.,Klinik Und Hochschulambulanz Für Neurologie Mit Abteilung Für Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany.,ExcellenceCluster NeuroCure, Berlin, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Department of Cardiology & Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Gießen, Gießen, Germany
| | - Christoph Jensen
- B. Braun Ambulantes Herzzentrum Kassel MVZ GmbH, Kassel, Germany.,Ruhr University Bochum, Bochum, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.,Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Grigorios Korosoglou
- Department of Cardiology and Vascular Medicine, GRN Hospital Weinheim, Weinheim, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center and Department for Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Tobias Neumann-Haefelin
- Department of Neurology, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, Goethe-University Hospital Frankfurt, Frankfurt, Germany.,Department of Neurology and Clinical Neurophysiology, Klinikum Lüneburg, Lüneburg, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff-Heart-Center, Bad Nauheim, Germany and Campus Kerckhoff Justus-Liebig-University, Gießen, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Wolf Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany.,Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany.,University Medical Center Goettingen, Göttingen, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany. .,Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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6
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Beheshtian E, Pakpoor J, Huntley JH, Sahraian S, Urrutia V, Khan MK, Idowu O, Yousem DM. Vascular imaging in the initial evaluation of embolic stroke source. Clin Imaging 2020; 68:278-282. [PMID: 32916508 DOI: 10.1016/j.clinimag.2020.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/04/2020] [Accepted: 07/13/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE During acute ischemic stroke evaluations, neurovascular imaging is commonly performed to localize the source of a thromboembolus and to identify vascular stenoses. In this study, we aimed to analyze 1) the usefulness of intracranial and/or cervical CTA and MRA and carotid doppler ultrasound (DUS) for identifying the stroke source and 2) the incidence of vascular stenoses across stroke etiologies. METHODS We retrospectively reviewed intracranial and/or cervical CTA, DUS and MRA studies to identify the source of the acute stroke by Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria for 200 consecutive patients admitted with a stroke to our tertiary hospital. Stroke etiologies were ascertained and the rates of intracranial and cervical vascular stenoses were stratified by stroke type. RESULTS Of 200 patients, the most probable sources of stroke were small vessel disease (29%), cardioembolic (26.0%) and atheroembolic (23.5%). Across all groups, 27.5% of patients had ≥70% stenosis on neurovascular imaging. The rate of ≥70% vascular stenosis in the neck was 6.9% and 5.8% in the small vessel and cardioembolic categories, respectively. CONCLUSIONS The TOAST etiologies of strokes were nearly equally distributed. Neurovascular imaging was of high utility for identifying large vessel intracranial stenoses in patients presenting with acute stroke across all etiologies, although neck CTA/MRA had a lower rate of positive studies with cardiogenic and small vessel strokes. These findings have implications on the use of CTA/MRA in acute stroke work-up.
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Affiliation(s)
- Elham Beheshtian
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287, USA.
| | - Jina Pakpoor
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19107, USA
| | - Joseph H Huntley
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287, USA; Eastern Virginia Medical School, Norfolk, VA, USA
| | - Sadaf Sahraian
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Victor Urrutia
- Department of Neurology, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Majid K Khan
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Oluwatoyin Idowu
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - David M Yousem
- Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 600 N Wolfe St, Baltimore, MD 21287, USA
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7
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Abstract
PURPOSE OF REVIEW Cardiac imaging after ischemic stroke or transient ischemic attack (TIA) is used to identify potential sources of cardioembolism, to classify stroke etiology leading to changes in secondary stroke prevention, and to detect frequent comorbidities. This article summarizes the latest research on this topic and provides an approach to clinical practice to use cardiac imaging after stroke. RECENT FINDINGS Echocardiography remains the primary imaging method for cardiac work-up after stroke. Recent echocardiography studies further demonstrated promising results regarding the prediction of non-permanent atrial fibrillation after ischemic stroke. Cardiac magnetic resonance imaging and computed tomography have been tested for their diagnostic value, in particular in patients with cryptogenic stroke, and can be considered as second line methods, providing complementary information in selected stroke patients. Cardiac imaging after ischemic stroke or TIA reveals a potential causal condition in a subset of patients. Whether systematic application of cardiac imaging improves outcome after stroke remains to be established.
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Affiliation(s)
- S Camen
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research) (partner site Hamburg/Kiel/Luebeck), Berlin, Germany
| | - K G Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - R B Schnabel
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.
- DZHK (German Center for Cardiovascular Research) (partner site Hamburg/Kiel/Luebeck), Berlin, Germany.
- University Heart Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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8
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Groeneveld NS, Guglielmi V, Leeflang MMG, Matthijs Boekholdt S, Nils Planken R, Roos YBWEM, Majoie CBLM, Coutinho JM. CT angiography vs echocardiography for detection of cardiac thrombi in ischemic stroke: a systematic review and meta-analysis. J Neurol 2020; 267:1793-1801. [PMID: 32140869 PMCID: PMC7293690 DOI: 10.1007/s00415-020-09766-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 12/29/2022]
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.
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Affiliation(s)
| | - Valeria Guglielmi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mariska M G Leeflang
- Department of Clinical Epidemiology and Biostatistics and Bioinformatics Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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9
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Lövblad KO, Bouchez L, Altrichter S, Ratib O, Machi P, Vargas MI, Sztajzel R. The role of advanced neuroimaging techniques in ischemic stroke prevention. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x19881446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
In great part due to recent advances in medical technology, ischemic cerebral stroke has become an increasingly treatable condition, which requires urgent measures and which rely on pharmacological and/or interventional measures. Due to its high prevalence, preventive measures should also be undertaken, and this is a situation where the use of advanced neuroimaging techniques could be helpful in certain underlying diseases. What is proposed here is to discuss how modern neuroimaging techniques (advanced magnetic resonance (MR) techniques and/or nuclear medicine techniques such as positron emission tomography (PET)) could help in situations that would otherwise lead to a stroke. Since both primary and secondary prevention measures are often required, we see that the techniques can be helpful in both situations. The diseases that cause stroke that can be investigated are, among others, carotid stenosis; transient ischemic attacks (TIAs) may also be followed by a major stroke if nothing is undertaken. It has been established that carotid stenosis is to be treated in the presence of a significant lesion that has neurological symptoms. The question of how to deal with these patients often arises when the relationship between the stenosis and symptoms is not significant or the symptomatology unclear. In such situations, either PET and/or fat-saturated T1 images of the carotids can help to demonstrate the embolic nature of the plaque. We have seen that carotid plaque vulnerability, which can cause embolism, can be associated with plaque inflammation (seen on PET) or plaque haemorrhage (seen on MR images). Also, while PET and MRI will demonstrate different stages of plaque vulnerability, they can both help to demonstrate vascular lesions that are at risk of causing significant ischemic events. Diffusion-weighted imaging (DWI) has shown that some TIAs may indeed be ischemic brain lesions with a transient symptomatology. The early use of DWI can thus help treat these patients more acutely. Based on this, we have seen that newer imaging techniques can provide additional knowledge about conditions that may lead to stroke and be treated. This should have a major impact on patient outcomes and ultimately on healthcare costs related to this condition.
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Affiliation(s)
- Karl-Olof Lövblad
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Laurie Bouchez
- Division of Radiology, Geneva University Hospitals, Geneva, Switzerland
| | - Stephen Altrichter
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Osman Ratib
- Division of Nuclear Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Paolo Machi
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Maria Isabel Vargas
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Roman Sztajzel
- Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
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Abstract
About 20–25% of all ischemic strokes are of cardioembolic etiology, with atrial fibrillation and heart failure as the most common underlying pathologies. Diagnostic work-up by noninvasive cardiac imaging is essential since it may lead to changes in therapy, e.g., in—but not exclusively—secondary stroke prevention. Echocardiography remains the cornerstone of cardiac imaging after ischemic stroke, with the combination of transthoracic and transesophageal echocardiography as gold standard thanks to their high sensitivity for many common pathologies. Transesophageal echocardiography should be considered as the initial diagnostic tool when a cardioembolic source of stroke is suspected. However, to date, there is no proven benefit of transesophageal echocardiography-related therapy changes on the main outcomes after ischemic stroke. Based on the currently available data, cardiac computed tomography and magnetic resonance imaging should be regarded as complementary methods to echocardiography, providing additional information in specific situations; however, they cannot be recommended as first-line modalities.
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Affiliation(s)
- S Camen
- Department of General and Interventional Cardiology, Building O70, University Heart Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - K G Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - R B Schnabel
- Department of General and Interventional Cardiology, Building O70, University Heart Center Hamburg, Martinistraße 52, 20246, Hamburg, Germany. .,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany.
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11
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Sugrue G, O'Reilly MK, Byrne D, Crockett MT, Murphy S, Kavanagh EC. CT cervico-cerebral angiography in acute stroke. Can we justify aortic arch imaging? Ir J Med Sci 2018; 188:661-666. [PMID: 30143966 DOI: 10.1007/s11845-018-1888-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 08/14/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Computed tomography cervico-cerebral angiography (CTCCA) plays a pivotal role in the evaluation of acute stroke. Currently no evidence justifies the inclusion of the upper chest in the CTCCA field of view. The aim of this study was to assess the prevalence and clinical significance of vascular findings identified on CTCCA in the head, neck, and upper chest regions in patients presenting with acute stroke symptoms. METHODS A retrospective review of radiology images and reports of 900 consecutive patients (425 men, 475 women; mean age 63.2 years, age range 19-99 years) with a suspected acute stroke who underwent CTCCA in the emergency department between January 2011 and July 2016. Clinically significant vascular CTCCA findings were recorded for each patient within the head, neck, and upper chest regions, respectively. RESULTS Of the 900 patients, clinically significant vascular CTCCA findings were identified in 404/900 (44.8%) patients. 218/900 (24.2%) were located within the head region; 174/900 (19.3%) within the neck; and 12/900 (2.4%) in the upper chest. Of the 12 vascular findings located within the upper chest, 3/900 (0.33%) were related to a clinically significant posterior circulation infarct. CONCLUSIONS Routine inclusion of the upper chest on CTCCA is currently difficult to justify in the evaluation of a suspected acute anterior circulation stroke, contributing significantly to total radiation dose without demonstrating significant extra-cranial vascular findings. Prospective studies adopting narrower fields of view excluding the upper chest are necessary.
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Affiliation(s)
- Gavin Sugrue
- Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland.
| | - Michael K O'Reilly
- Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Danielle Byrne
- Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Matthew T Crockett
- Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Sean Murphy
- Department of Stroke Medicine, Mater Misericordiae University Hospital, Dublin 7, Ireland
| | - Eoin C Kavanagh
- Department of Radiology, Mater Misericordiae University Hospital, Dublin 7, Ireland
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12
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Peultier AC, Redekop K, Coche E, Severens JL. What are the images used to diagnose and assess suspected strokes?: A systematic literature review of care in four European countries. Expert Rev Pharmacoecon Outcomes Res 2018; 18:177-189. [PMID: 29400089 DOI: 10.1080/14737167.2018.1429270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The cost-effectiveness of clinical interventions is often assessed using current care as comparator. However, evidence suggests practice variation in stroke imaging across countries. For the purpose of feeding into cost-effectiveness analysis, this research aims to describe the patterns of stroke imaging, examine practice variations across countries and, as such, obtain results reflecting current care. AREAS COVERED A systematic literature review was conducted to identify original studies reporting the imaging workup used in acute stroke care in clinical practice in Hungary, Germany, Sweden and the UK. Information regarding the type and frequency of stroke imaging was analysed. Computed Tomography (CT) was reported as the main diagnostic imaging modality used in stroke care (78-98% across patient profiles and time periods). This review revealed patterns that were not observed in individual studies. Comparisons of UK studies revealed considerable variations in the proportion of scanned patients and timing of imaging. EXPERT COMMENTARY While the evidence about thrombectomy is difficult to translate in clinical practice, the evidence regarding the optimal imaging approach to diagnose stroke patients is lacking. The heterogeneity in stroke imaging reinforces the need to compare the quality of stroke care within and between countries.
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Affiliation(s)
- Anne-Claire Peultier
- a Erasmus School of Health Policy and Management , Erasmus University Rotterdam , Rotterdam , The Netherlands
| | - Ken Redekop
- a Erasmus School of Health Policy and Management , Erasmus University Rotterdam , Rotterdam , The Netherlands.,b Institute for Medical Technology Assessment , Erasmus University Rotterdam , Rotterdam , The Netherlands
| | - Emmanuel Coche
- c Department of Radiology , Cliniques Universitaires St-Luc, Université Catholique de Louvain , Brussels , Belgium
| | - Johan L Severens
- a Erasmus School of Health Policy and Management , Erasmus University Rotterdam , Rotterdam , The Netherlands.,b Institute for Medical Technology Assessment , Erasmus University Rotterdam , Rotterdam , The Netherlands
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13
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Hur J, Choi BW. Cardiac CT Imaging for Ischemic Stroke: Current and Evolving Clinical Applications. Radiology 2017; 283:14-28. [DOI: 10.1148/radiol.2016152043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jin Hur
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemungu, 120-752, Seoul, Republic of Korea
| | - Byoung Wook Choi
- From the Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemungu, 120-752, Seoul, Republic of Korea
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Impact of Implementing Cardiac CT in Evaluating Patients Suspected of Cardioembolic Stroke. J Comput Assist Tomogr 2017; 40:380-6. [PMID: 26854417 DOI: 10.1097/rct.0000000000000369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES In practice, clinical and logistic hurdles may hamper performing transesophageal echocardiography in stroke patients. Cardiac computed tomography (CT) is a recently introduced noninvasive modality able to detect various embolic causes. Thus, we retrospectively assessed possible added values of applying cardiac CT in the real-world work-up of suspected cardioembolic stroke cases. METHODS Forty-seven patients were neurology service referrals for suspected cardioembolic stroke. The CT images and clinical reports of our cardiac CT radiologists were retrospectively evaluated. Cardiac CT was assessed in terms of detecting major embolic potential findings, potentially significant stroke-unrelated findings, and coronary arterial disease (CAD). Computed tomography results were correlated with echocardiographic reports. RESULTS Cardiac CT showed findings of major embolic potential in 10 patients (21%, 5 thrombi cases, 2 vasculitis cases, 1 case of metastasis invading the left superior pulmonary artery, 1 myocardial infarction case, and 1 pulmonary arteriovenous malformations case), none of which were documented in echocardiography reports. Two cases (4%) with findings of major embolic potential where identified on echocardiography but not on CT (1 left atrial appendage thrombus and 1 mitral valve vegetation). Computed tomography of 13 patients (28%) showed 16 potentially significant stroke-unrelated findings. Twenty-one patients (47%) had unexpected CAD on CT, 11 (52%) of which were obstructive. CONCLUSIONS Implementing cardiac CT in assessing patients suspected of cardioembolic stroke added value to echocardiographic evaluation, by detecting major embolic potential findings. In addition, cardiac CT revealed additional potentially significant stroke-unrelated findings and CAD.
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Eid M, De Cecco CN, Schoepf UJ, Mangold S, Tesche C, Varga-Szemes A, Suranyi P, Stalcup S, Ball BD, Caruso D. The Role of MRI and CT in the Diagnosis of Atherosclerosis in an Aging Population. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-016-0141-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cardioembolism and Involvement of the Insular Cortex in Patients with Ischemic Stroke. PLoS One 2015; 10:e0139540. [PMID: 26489090 PMCID: PMC4619548 DOI: 10.1371/journal.pone.0139540] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 08/13/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To evaluate whether topographical characteristics of insular involvement in ischemic stroke are associated with cardioembolism. METHODS AND FINDINGS A consecutive series of patients hospitalized for ischemic stroke within 7 days of symptom onset were identified. Based on diffusion-weighted imaging, we included those who had ischemic lesions in the middle cerebral artery (MCA) territory. Each patient was assigned to one of two groups based on the presence or absence of insular involvement. The primary outcome was the frequency of cardioembolism, which was compared based on insular involvement. Of 1,311 patients with ischemic stroke in the MCA territory, 112 had insular involvement (8.5%). The frequency of cardioembolism in patients with insular involvement (52.7%) was significantly higher than that in patients without insular involvement (30.4%, P < 0.001). Although insular involvement was associated with a severe baseline National Institutes of Health Stroke Scale score (13 vs. 4), it did not independently affect the 3-month functional outcome. CONCLUSIONS In cases of stroke in the MCA territory, involvement of the insular cortex may be associated with a risk of cardioembolism.
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Tsai CC, Wu MN. Frequent Ischemic Stroke as First Manifestation of Occult Colon Cancer: A Rare Case. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:723-7. [PMID: 26460069 PMCID: PMC4610689 DOI: 10.12659/ajcr.895130] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patient: Male, 46 Final Diagnosis: Adenocarcinoma of the ascending colon Symptoms: Anemia • diplopia • hemiparesis • slurred speech Medication: — Clinical Procedure: Multi-detector computed tomography • colonoscopy Specialty: Neurology
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Affiliation(s)
- Chia-Chan Tsai
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Meng-Ni Wu
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Pacheco FT, Littig IA, Gagliardi RJ, Rocha AJD. Multidetector computed tomography angiography in clinically suspected hyperacute ischemic stroke in the anterior circulation: an etiological workup in a cohort of Brazilian patients. ARQUIVOS DE NEURO-PSIQUIATRIA 2015; 73:408-14. [PMID: 26017206 DOI: 10.1590/0004-282x20150034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 01/28/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The potential of computed tomography angiography (CTA) was assessed for early determination of stroke subtypes in a Brazilian cohort of patients with stroke. METHOD From July 2011 to July 2013, we selected patients with suspected hyperacute stroke (< 6 hours). Intracranial and cervical arteries were scrutinized on CTA and their imaging features were correlated with concurrent subtype of stroke. RESULTS Stroke was documented in 50/106 selected patients (47.2%) based on both clinical grounds and imaging follow-up (stroke group), with statistically significant arterial stenosis and vulnerable plaques on CTA. Intracranial large artery disease was demonstrated in 34% of patients in the stroke group. Partial territorial infarct prevailed (86%) while artery-to-artery embolization was the most common stroke mechanism (52%). CONCLUSION Multidetector CTA was useful for the etiologic work-up of hyperacute ischemic stroke and facilitated the knowledge about the topographic pattern of brain infarct in accordance with its causative mechanism.
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Affiliation(s)
- Felipe Torres Pacheco
- Departamento de Neuroradiologia, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Ingrid Aguiar Littig
- Departamento de Neuroradiologia, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Rubens Jose Gagliardi
- Departamento de Neurologia, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil
| | - Antônio Jose da Rocha
- Departamento de Neuroradiologia, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brazil
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Deipolyi AR, Hamberg LM, Gonzaléz RG, Hirsch JA, Hunter GJ. Diagnostic yield of emergency department arch-to-vertex CT angiography in patients with suspected acute stroke. AJNR Am J Neuroradiol 2015; 36:265-8. [PMID: 25258370 DOI: 10.3174/ajnr.a4112] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to investigate how often relevant diagnostic findings in an arch-to-vertex CTA scan, obtained specifically as part of the acute stroke CT protocol, are located in the head, neck, and upper chest regions. MATERIALS AND METHODS Radiology reports were reviewed in 302 consecutive patients (170 men, 132 women; median ages, 66 and 73 years, respectively) who underwent emergency department investigation of suspected acute stroke between January and July 2010. Diagnostic CTA findings relevant to patient management were recorded for the head, neck, and chest regions individually. Additionally, the contributions to the total CTA scan effective dose were estimated from each of the 3 anatomic regions by using the ImPACT CT Dose Calculator. RESULTS Of the 302 patients, 161 (54%) had relevant diagnostic findings in the head; 94 (31%), in the neck; and 4 (1%), in the chest. The estimated contributions to the total CTA scan dose from each body region, head, neck, and upper chest, were 14 ± 2%, 33 ± 5%, and 53 ± 6%, respectively. CONCLUSIONS Most clinically relevant findings are in the head and neck, supporting inclusion of these regions in arch-to-vertex CTA performed specifically in patients with acute stroke in the emergency department. Further studies are required to investigate extending the scan to the upper chest because only 1% of patients in our study had clinically relevant findings in the mediastinum, yet half the CTA effective dose was due to scanning in this region.
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Affiliation(s)
- A R Deipolyi
- From the Department of Radiology (A.R.D., R.G.G., J.A.H., G.J.H.), Massachusetts General Hospital, Boston, Massachusetts
| | - L M Hamberg
- Department of Radiology (L.M.H.), Brigham and Women's Hospital, Boston, Massachusetts
| | - R G Gonzaléz
- From the Department of Radiology (A.R.D., R.G.G., J.A.H., G.J.H.), Massachusetts General Hospital, Boston, Massachusetts
| | - J A Hirsch
- From the Department of Radiology (A.R.D., R.G.G., J.A.H., G.J.H.), Massachusetts General Hospital, Boston, Massachusetts
| | - G J Hunter
- From the Department of Radiology (A.R.D., R.G.G., J.A.H., G.J.H.), Massachusetts General Hospital, Boston, Massachusetts
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20
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Emerging Role of Cardiovascular CT and MRI in the Evaluation of Stroke. AJR Am J Roentgenol 2015; 204:269-80. [DOI: 10.2214/ajr.14.13051] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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21
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Mechtouff L, Boussel L, Cakmak S, Lamboley JL, Bourhis M, Boublay N, Schott AM, Derex L, Cho TH, Nighoghossian N, Douek PC. Multilevel assessment of atherosclerotic extent using a 40-section multidetector scanner after transient ischemic attack or ischemic stroke. AJNR Am J Neuroradiol 2013; 35:568-72. [PMID: 24136645 DOI: 10.3174/ajnr.a3760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The first part of this study assessed the potential of MDCT with a CTA examination of the aorta and the coronary, cervical, and intracranial vessels in the etiologic work-up of TIA or ischemic stroke compared with established imaging methods. The objective of the second part of this study was to assess the atherosclerotic extent by use of MDCT in these patients. MATERIALS AND METHODS From August 2007 to August 2011, a total of 96 patients with ischemic stroke or TIA without an evident cardioembolic source were enrolled. All patients underwent MDCT. Atherosclerotic extent was classified in 0, 1, 2, 3, and 4 atherosclerotic levels according to the number of arterial territories (aortic arch, coronary, cervical, intracranial) affected by atherosclerosis defined as ≥ 50% cervical, intracranial, or coronary stenosis or ≥ 4-mm aortic arch plaque. RESULTS There were 91 patients who had an interpretable MDCT. Mean age was 67.4 years (± 11 years), and 75 patients (83.3%) were men. The prevalence of 0, 1, 2, 3, and 4 atherosclerotic levels was 48.3%, 35.2%, 12.1%, 4.4%, and 0%, respectively. Aortic arch atheroma was found in 47.6% of patients with 1 atherosclerotic level. The combination of aortic arch atheroma and cervical stenosis was found in 63.6% of patients with ≥ 2 atherosclerotic levels. Patients with ≥ 2 atherosclerotic levels were older than patients with < 2 atherosclerotic levels (P = .04) in univariate analysis. CONCLUSIONS MDCT might be useful to assess the extent of atherosclerosis. It could help to screen for high-risk patients who could benefit from a more aggressive preventive strategy.
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Affiliation(s)
- L Mechtouff
- From the Stroke Unit (L.M., L.D., T.-H.C., N.N.), Hôpital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
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Kamalian S, Kamalian S, Pomerantz SR, Tanpitukpongse TP, Gupta R, Romero JM, Katz DS. Role of cardiac and extracranial vascular CT in the evaluation/management of cerebral ischemia and stroke. Emerg Radiol 2013; 20:417-28. [DOI: 10.1007/s10140-013-1116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 03/03/2013] [Indexed: 01/09/2023]
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Sipola P, Hedman M, Onatsu J, Turpeinen A, Halinen M, Jäkälä P, Vanninen R. Computed Tomography and Echocardiography together Reveal More High-Risk Findings than Echocardiography Alone in the Diagnostics of Stroke Etiology. Cerebrovasc Dis 2013; 35:521-30. [DOI: 10.1159/000350734] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/05/2013] [Indexed: 11/19/2022] Open
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Hur J, Kim YJ, Lee HJ, Nam JE, Hong YJ, Kim HY, Lee JW, Choi BW. Cardioembolic Stroke: Dual-Energy Cardiac CT for Differentiation of Left Atrial Appendage Thrombus and Circulatory Stasis. Radiology 2012; 263:688-95. [DOI: 10.1148/radiol.12111691] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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25
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Small GR, Ruddy TD. PET imaging of aortic atherosclerosis: Is combined imaging of plaque anatomy and function an amaranthine quest or conceivable reality? J Nucl Cardiol 2011; 18:717-28. [PMID: 21553158 DOI: 10.1007/s12350-011-9385-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Traditionally, blood vessels have been studied using contrast luminography to determine the site, extent and severity of luminal compromise by atherosclerotic deposits. Similar anatomical data can now be acquired non-invasively using ultrasound, computed tomography or magnetic resonance imaging. Plaque stability is an important determinant of subsequent vascular events and currently functional data on the stability of plaque is less well provided by these methods. The search for non-invasive techniques to image combined plaque anatomy and function has been pursued with visionary anticipation. This expectation may soon be realised as imaging with radionuclide-labelled atheroma-targeted contrast agents has demonstrated that plaque functional characteristics can now be shown. Increasingly positron emission tomography/computed tomography (PET/CT) imaging with (18)F fluorodexoyglucose (FDG) and other radionuclides is being used to determine culprit plaques in complex clinically scenarios. Clinically, this information may prove extremely valuable in the assessment of stable and unstable patients and its use in prime time medical practice is eagerly awaited. We will discuss the current clinical applications of functional atheroma imaging in the aorta and highlight the promising preclinical data on novel image biomarkers of plaque instability. If clinical science is able to successfully translate these advances in vascular imaging from the bench to the bedside, a new paradigm will be achieved in cardiovascular diagnostics.
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Affiliation(s)
- Gary R Small
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
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Young VEL, Degnan AJ, Gillard JH. Advances in contrast media for vascular imaging of atherosclerosis. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/iim.11.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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