From the Departments of Radiology (S.G., H.K., A.M., M.A., D.F.K., R.K.), Neurologic Surgery (S.G., R.K.), and Neurology (M.L., A.A.R., D.N.), Mayo Clinic, Rochester, MN; Evidence-based Practice Center (A.S.A.), Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN; Neuroendovascular Program (A.A.D.), Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Neurovascular Centre, Divisions of Therapeutic Neuroradiology & Neurosurgery (A.A.D.), St. Michael's Hospital, University of Toronto, ON, Canada.
Neurology. 2024 Oct 8;103(7):e209771. doi: 10.1212/WNL.0000000000209771. Epub 2024 Sep 13.
Ischemic stroke, a leading cause of mortality, necessitates understanding its mechanism for effective prevention. Echocardiography, especially transesophageal echocardiography (TEE), is the gold standard for detection of cardiac sources of stroke including left atrial thrombus, although its invasiveness, operator skill dependence, and limited availability in some centers prompt exploration of alternatives, such as cardiac CT (CCT). We conducted a systematic review and meta-analysis assessing the ability of CCT in the detection of intracardiac thrombus compared with echocardiography.
We searched 4 databases up through September 8, 2023. Major search terms included a combination of the terms "echocardiograph," "CT," "TEE," "imaging," "stroke," "undetermined," and "cryptogenic." The current systematic literature review of the English language literature was reported in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. We assessed risk of bias using the QUADAS-2 tool and used random-effects meta-analysis to calculate different diagnostic metrics.
The meta-analysis investigating CCT vs echocardiography for intracardiac thrombus detection yielded a total of 43 studies of 9,552 patients. Risk-of-bias assessment revealed a predominantly low risk of bias in the flow and timing, index test, and patient selection domains and a predominantly unclear risk of bias in the reference standard domain. The analysis revealed an overall sensitivity of 98.38% (95% CI 89.2-99.78) and specificity of 96.0% (95% CI 92.55-97.88). Subgroup analyses demonstrated that delayed-phase, electrocardiogram-gated CCT had the highest sensitivity (100%; 95% CI 0-100) while early-phase, nongated CCT exhibited a sensitivity of 94.31% (95% CI 28.58-99.85). The diagnostic odds ratio was 98.59 (95% CI 44.05-220.69). Heterogeneity was observed, particularly in specificity and diagnostic odds ratio estimates.
CCT demonstrates high sensitivity, specificity, and diagnostic odds ratios in detecting intracardiac thrombus compared with traditional echocardiography. Limitations include the lack of randomized controlled studies, and other cardioembolic sources of stroke such as valvular disease, cardiac function, and aortic arch disease were not examined in our analysis. Large-scale studies are warranted to further evaluate CCT as a promising alternative for identifying intracardiac thrombus and other sources of cardioembolic stroke.
缺血性脑卒中是一种主要的致死病因，需要深入了解其发病机制，以便进行有效的预防。超声心动图，特别是经食管超声心动图（TEE），是检测心源性脑卒中的金标准，包括左心房血栓，但因其具有侵袭性、操作者技能依赖性，以及在某些中心的可用性有限，促使人们探索其他替代方法，如心脏 CT（CCT）。我们进行了一项系统评价和荟萃分析，评估 CCT 在检测心内血栓方面与超声心动图相比的能力。
我们检索了截至 2023 年 9 月 8 日的 4 个数据库。主要搜索词包括“超声心动图”、“CT”、“TEE”、“成像”、“中风”、“未确定”和“隐源性”等术语的组合。本系统综述按照系统评价和荟萃分析报告的首选报告项目（PRISMA）指南进行。我们使用 QUADAS-2 工具评估偏倚风险，并使用随机效应荟萃分析计算不同的诊断指标。
荟萃分析调查了 CCT 与超声心动图检测心内血栓的情况，共纳入了 43 项研究，涉及 9552 例患者。偏倚风险评估显示，在流程和时间、索引测试和患者选择方面主要为低风险，而在参考标准方面主要为不确定风险。分析显示，总体敏感性为 98.38%（95%CI 89.2-99.78），特异性为 96.0%（95%CI 92.55-97.88）。亚组分析表明，延迟相、心电图门控 CCT 的敏感性最高（100%；95%CI 0-100），而非门控早期 CCT 的敏感性为 94.31%（95%CI 28.58-99.85）。诊断比值比为 98.59（95%CI 44.05-220.69）。存在异质性，特别是在特异性和诊断比值比估计方面。
与传统超声心动图相比，CCT 在心内血栓检测方面具有较高的敏感性、特异性和诊断比值比。局限性包括缺乏随机对照研究，以及我们的分析中未检查其他心源性脑卒中的栓子来源，如瓣膜疾病、心功能和主动脉弓疾病。需要进行大规模研究，以进一步评估 CCT 作为一种有前途的替代方法，用于识别心内血栓和其他心源性脑卒中的栓子来源。
