Angela Salemi1, Matthew Yanus2, Tony Zhang3, Riya Bhavsar4, Danish Kherani5, Himanshu Patel6, Alan Pan3, Farhaan Vahidy3, Charles McCane3, David Chiu4, Rajan Gadhia7, John Volpi3, Tanu Garg4
1Houston Methodist Neurology Department, 2Methodist Hospital, 3Houston Methodist, 4Houston Methodist Hospital, 5UTHealth Houston Memorial Hermann, 6University of Maryland, 7Houston Methodist Hospital, WCMC
Objective:
To describe the sensitivity, specificity, and negative and positive predictive values of abnormal TTE for detection of intracardiac thrombus on advanced cardiac imaging, to better characterize factors likely to predict finding an abnormality on advanced cardiac imaging in cryptogenic strokes.
Background:
Despite advances in medical technology, 20-30% of strokes are still classified as cryptogenic. A large portion of these strokes are presumed to be ESUS. Current AHA guidelines recommend (class IIb) advanced cardiac imaging in ESUS.
Design/Methods:
A retrospective review of stroke patients at a comprehensive stroke center who had cardiac CT or MRI between 12/2016 and 11/2020 was conducted using institutional registries. Ischemic stroke patients with cryptogenic etiologies were included. Cases with TIA, cardioembolic, large vessel, small vessel, or hemodynamic etiologies were excluded. TTE and cardiac CT/MRI results from all cases were reviewed for remarkable findings, most notably intracardiac thrombus, and presence of TTE abnormalities were analyzed. TTE abnormalities were defined as wall motion abnormalities, reduced LVEF <50%, and/or severe left atrial enlargement.
Results:
Two-hundred eighty-five cases (Female 45%, Caucasian 59%, Age mean: 64.4 years) were included, of whom 98 (34%) were cryptogenic and 187 (66%) were ESUS. Twelve (4.2%) revealed intracardiac thrombus, of which 9 had LV thrombus, 2 had LA thrombus, and 1 had RAA thrombus. Two were diagnosed with cardiac CT and 10 with cMRI. Of these, 10 had abnormal wall motion abnormalities on TTE, 6 had low LVEF, and 3 had severe left atrial enlargement. The sensitivity and specificity of abnormal TTE were 100% and 76.9% for an intracardiac thrombus. Abnormal TTE had a positive and negative predictive value of 16% and 100%.
Conclusions:
In this retrospective analysis of select stroke cases, abnormal TTE findings had high sensitivity in the detection of intracardiac thrombus on advanced cardiac imaging. A normal TTE had a high negative predictive value.