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Cardiac CT in LVO Stroke

Cardiac CT in Large Vessel Occlusion Stroke for the Evaluation of Non-Thrombotic and Non-Atrial-Fibrillation-Related Embolic Causes

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Year of Publication: 2025

Authors: Karim Mostafa, Cosima Wünsche, Sarah Krutmann, ..., Patrick Langguth

Journal: Neurology International

Citation: Neurol Int. 2025;17:25.

Link: https://doi.org/10.3390/neurolint17020025

PDF: https://mdpi-res.com/d_attachment/neurol...sion=1738922506

Clinical Question

In patients with acute LVO stroke without atrial fibrillation or intracardiac thrombus, which cardiac CT findings are independently associated with a cardioembolic stroke aetiology?

Bottom Line

In 121 LVO stroke patients without AF or intracardiac thrombus, five cardiac CT findings were independently associated with cardioembolic aetiology: LV dilatation (AOR 32.4; P=0.004), visible interatrial R-to-L shunt (AOR 30.8; P=0.006), aortic/mitral valve implants (AOR 24.5; P=0.009), aortic arch atheroma grade >II (AOR 6.9; P=0.015), and post-ischemic myocardial scar (AOR 6.3; P=0.032). Combined model AUC=0.83.

Major Points

  • Cardioembolic cause in 70.2% of all LVO patients (221/315); AF+thrombus explained 86.9%.
  • After excluding AF/thrombus, only 24% (29/121) cardioembolic — vs 47.1% ESUS.
  • LV dilatation strongest predictor: AOR 32.4 (95% CI 3.0-349; P=0.004).
  • Visible interatrial R→L shunt: AOR 30.8 (95% CI 2.7-341.3; P=0.006) — present in 3.3%.
  • Valve implants (aortic/mitral): AOR 24.5 (95% CI 2.2-270.9; P=0.009) — present in 4.1%.
  • Aortic arch atheroma grade >II (≥4mm): AOR 6.9 (95% CI 1.5-32.8; P=0.015) — present in 10.7%.
  • Post-ischemic myocardial scar: AOR 6.3 (95% CI 1.2-34.1; P=0.032) — present in 9.1%.
  • Combined 5-factor model AUC=0.83.
  • ESUS was largest aetiology (47.1%) in the analytic cohort — highlighting need for better detection tools.
  • Cardiac CT additional radiation: median DLP only 265 mGy*cm — low relative to benefit.

Design

Study Type: Retrospective observational cohort study

Randomization:

Blinding: Not applicable (retrospective imaging analysis)

Enrollment Period: 2018-2024

Follow-up Duration: Inpatient stroke unit evaluation

Centers: 1

Countries: Germany

Sample Size: 121

Analysis: Multivariate logistic regression; ROC analysis. Full cohort 315, analytic cohort 121 (no AF, no thrombus).

Inclusion Criteria

  • Intracranial large vessel occlusion confirmed on CT angiography.
  • Cardiac CT available from acute stroke setting.
  • Absence of intracardiac thrombus on cardiac CT.
  • Absence of atrial fibrillation (history, chart, 24h ECG).

Exclusion Criteria

  • Known or newly diagnosed atrial fibrillation.
  • Intracardiac thrombus on cardiac CT.
  • No available cardiac CT from acute setting.
  • No confirmed LVO on CTA.

Baseline Characteristics

Analytic Cohort (N=121, no AF/thrombus):

  • Female sex: 64 (52.9%)
  • Age (mean±SD): 69.4±16.1
  • Hypertension: 66 (54.5%)
  • Diabetes: 18 (14.9%)
  • Smoker: 28 (23.1%)
  • Hyperlipidemia: 25 (20.7%)
  • CHF: 9 (7.4%)
  • TTE performed: 82 (67.8%)
  • TEE performed: 26 (21.5%)
  • TOAST Cardioembolic: 29 (24.0%)
  • TOAST Large artery: 28 (23.1%)
  • TOAST ESUS: 57 (47.1%)
  • Vessel — MCA: majority
  • Vessel — Carotid-T: subset

Arms

FieldObservational cohort
InterventionRetrospective analysis of cardiac CT findings in LVO stroke patients without AF/thrombus. TOAST classification as outcome.
DurationInpatient

Outcomes

OutcomeTypeControlInterventionHR / OR / RRP-value
Independent cardiac CT predictors of cardioembolic aetiology (multivariate logistic regression)PrimaryNon-cardioembolic (n=92)Cardioembolic (n=29)See individual predictors
LV dilatation → cardioembolic | 95% CI: 3.0-349Secondary—AOR 32.40.004
Visible interatrial R→L shunt → cardioembolic | 95% CI: 2.7-341.3Secondary—AOR 30.80.006
Aortic/mitral valve implant → cardioembolic | 95% CI: 2.2-270.9Secondary—AOR 24.50.009
Aortic arch atheroma grade >II → cardioembolic | 95% CI: 1.5-32.8Secondary—AOR 6.90.015
Post-ischemic myocardial scar → cardioembolic | 95% CI: 1.2-34.1Secondary—AOR 6.30.032
Observational imaging studyAdverseObservational study of cardiac CT for embolic source detection - no AE data

Subgroup Analysis

No formal subgroup analyses. Primary regression performed on n=121 analytic subcohort.

Criticisms

  • Very wide confidence intervals (AOR 3.0-349 for LV dilatation) — small events, likely overfitting.
  • Only 29 cardioembolic events with 5 predictor variables — violates rule of 10 events/variable.
  • Single-center retrospective design — cannot establish causality.
  • TOAST classification by interdisciplinary consensus, not fully blinded adjudication.
  • No comparison with TEE as gold standard for all patients (TEE only in 21.5%).
  • Selection bias: only LVO patients without AF/thrombus — small minority of all stroke.
  • No anticoagulation/antiplatelet data considered.

Funding

No external funding received.

Based on: Cardiac CT in LVO Stroke (Neurology International, 2025)

Authors: Karim Mostafa, Cosima Wünsche, Sarah Krutmann, ..., Patrick Langguth

Citation: Neurol Int. 2025;17:25.

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