← Back

CaCTUSES

Cardiac CT for intra-cardiac thrombus detection in embolic stroke of undetermined source (ESUS)

Share Share Copied! Compare

Year of Publication: 2022

Authors: Barnea R, Nardi Agmon I, Shafir G, ..., Hamdan A

Journal: European Stroke Journal

Citation: Barnea R, et al. Eur Stroke J. 2022;7(3):212–220.

Link: https://doi.org/10.1177/23969873221099692

Clinical Question

Does cardiac CT angiography (CCTA) improve the detection of intra-cardiac thrombus in ESUS patients and affect secondary prevention strategy?

Study Overview

Objective

To evaluate the diagnostic yield and clinical impact of cardiac CT angiography (CCTA) in detecting intra-cardiac thrombi in patients with embolic stroke of undetermined source (ESUS).

Study Summary

CCTA improved detection of intra-cardiac thrombus in ESUS patients compared to standard evaluation alone, identifying thrombi in nearly 1 in 5 patients.

Intervention

Cardiac CT angiography (CCTA) as an advanced imaging modality for ESUS workup in patients not undergoing transesophageal echocardiography (TEE).

Patients per Arm

129 ESUS patients underwent CCTA (subset of 266 total ESUS cases).

Bottom Line

In ESUS patients, cardiac CT detected intra-cardiac thrombus in 17% (22/129) — LV thrombus 10.1%, LAA thrombus 6.2%. Standard TTE missed 77% of these. CCTA changed management in 21% (27/129) from antiplatelet to anticoagulant. At population level, 8.2% of all ESUS patients (22/266) had thrombi detected only by CCTA. Predictors: IHD (59% vs 28%), CHF (40% vs 6%), reduced EF (mean 46% vs 57%), apical hypokinesia (59% vs 12%).

        Major Points
        CCTA detected thrombus in 17% (22/129) of ESUS patients: LVT 10.1%, LAA 6.2%, LA body 0.8%.
TTE missed 77% (17/22) of thrombi — only 5/22 even suspected on TTE.
Changed management in 21% (27/129) — antiplatelet to anticoagulant (thrombus n=22, PE n=7).
Population impact: 8.2% (22/266) of all ESUS patients had thrombi detectable only by CCTA.
Predictors: IHD (59% vs 28%; P=0.01), CHF (40% vs 6%; P<0.0001), reduced EF (46% vs 57%; P<0.0001), apical hypokinesia (59% vs 12%; P<0.0001).
All 13 LVTs in apex with wall motion abnormality. 2 had previously unknown prior MI (new dx on CCTA).
CCTA also found PE in 7 patients and subclinical leaflet thrombosis in 2.
Retrospective, single-center (Beilinson Hospital, Israel), 129 CCTA + 57 TEE patients.
TEE preferred in younger (<60yr) PFO candidates; CCTA preferred in older cardiovascular-risk patients.
Supports CCTA in routine ESUS workup, especially with apical hypokinesia, reduced EF, IHD, or CHF.

      

Design

Study Type: Retrospective observational study

Randomization:

Blinding:

Enrollment Period: April 1, 2019 to October 1, 2021

Centers: 1

Countries: Israel

Sample Size: 266

Analysis: Descriptive and comparative statistical analysis using SPSS

Inclusion Criteria

Non-lacunar ischemic stroke
Absence of AF on baseline ECG and in-hospital continuous cardiac telemetry monitoring of ≥20 h
Absence of ipsilateral arterial luminal stenosis >50% on vascular imaging
No other proven cardiac source of embolism on non-contrast transthoracic echo

Exclusion Criteria

TIA (transient ischemic attack)
Renal dysfunction (for contrast)
Inability to cooperate with CT (e.g., aphasia, instability)
Preference for TEE when evaluating valvular sources or PFO

Arms

Field	CCTA Group
Intervention	Cardiac CT angiography performed in ESUS patients
Duration	Single imaging during hospitalization

Outcomes

Outcome	Type	Intervention
Detection of intra-cardiac thrombus on CCTA	Primary	17%
Patients requiring anticoagulation based on CCTA \| 95% CI: 14%–28%	Secondary	21%
Overall detection of intra-cardiac thrombus in ESUS population \| 95% CI: 4.9%–11.5%	Secondary	8.2%
Observational study	Adverse	Retrospective observational study of cardiac CT in ESUS - no safety/AE data reported

Subgroup Analysis

CCTA more commonly detected thrombi in patients with CHF or IHD. LVT was associated with apical hypokinesia on echo.

Criticisms

Retrospective and single-center design
No comparison between CCTA and TEE in the same patients
No long-term outcomes reported
Selection bias due to imaging modality availability and patient stability

Funding

None reported

Based on: CaCTUSES (European Stroke Journal, 2022)