Mind the Heart: Electrocardiography-gated cardiac computed tomography-angiography in acute ischaemic stroke-rationale and study design

Valeria Guglielmi; Leon A Rinkel; Nina-Suzanne Groeneveld; Nick Hj Lobé; S Matthijs Boekholdt; Berto J Bouma; Ludo Fm Beenen; Henk A Marquering; Charles Blm Majoie; Yvo Bwem Roos; Adrienne van Randen; R Nils Planken; Jonathan M Coutinho

doi:10.1177/2396987320962911

Mind the Heart: Electrocardiography-gated cardiac computed tomography-angiography in acute ischaemic stroke-rationale and study design

Eur Stroke J. 2020 Dec;5(4):441-448. doi: 10.1177/2396987320962911. Epub 2020 Oct 11.

Affiliations

¹ Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
² Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
³ Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
⁴ Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.

Abstract

Rationale: About one-third of ischaemic strokes are caused by cardioembolism, and a substantial proportion of cryptogenic strokes likely also originate from the heart or aortic arch. Early determination of aetiology is important to optimise management. Computed Tomography-angiography of the heart is emerging as an alternative to echocardiography to detect cardio-aortic sources of embolism in stroke patients, but its diagnostic yield in acute ischaemic stroke has not been thoroughly assessed.Hypothesis: We hypothesise that electrocardiography-gated computed tomography-angiography of the heart and aortic arch, acquired in the acute phase in patients with ischaemic stroke, has a higher diagnostic yield than transthoracic echocardiography as a first-line screening method for detection of cardio-aortic sources of embolism.

Methods and design: Mind the Heart is a single-centre prospective observational cohort study. We will include consecutive adult patients with acute ischaemic stroke who are potentially eligible for reperfusion therapy. Patients undergo non-electrocardiography-gated computed tomography-angiography of the aortic arch, cervical and intracranial arteries, directly followed by prospective sequential electrocardiography-gated cardiac computed tomography-angiography. Routine work-up for cardioembolism including 12-leads electrocardiography, Holter electrocardiography and transthoracic echocardiography is performed as soon as possible. The primary endpoint is the proportion of patients with a predefined high-risk cardio-aortic source of embolism on computed tomography-angiography versus transthoracic echocardiography in patients who underwent both investigations. Based on an expected 5% additional yield of computed tomography-angiography, a sample size of 450 patients is required.

Conclusions: The Mind the Heart study will generate a reliable estimate of the diagnostic yield of echocardiography-gated cardio-aortic computed tomography-angiography performed in the acute phase of ischaemic stroke.

Keywords: Acute stroke; cardiac emboli; computed tomography angiography.