Marquering, Henk A.

Abstract Background and aims Cardiac CT is increasingly used in the acute diagnostic work-up of acute ischemic stroke (AIS), but commonly used scan protocols do not allow assessment of left ventricular ejection fraction (LVEF), a known predictor of functional outcome. We aimed to develop a prediction model for reduced LVEF using clinical and imaging data. Methods This post-hoc analysis of the Mind the Heart study included AIS patients who underwent acute cardiac CT (acquired during diastole) and routine diagnostic work-up, including transthoracic echocardiography (TTE), which served as the reference standard for LVEF. Multivariable logistic regression models incorporating baseline variables, arterial input function (AIF) derived from CT-perfusion, and left atrial and ventricular cardiac CT volumes were developed using the training set (80%) to predict reduced LVEF (<50%). Performance was evaluated on the testing set (20%) using receiver operating characteristic analysis, reporting the area under the curve (AUC), sensitivity, and specificity. Non-linear associations were modeled using restricted cubic splines, and Least Absolute Shrinkage and Selection Operator regression was used for variable selection. We evaluated whether cardiac CT information improved model fit. Results We included 298 AIS patients (61% male, median age 71 [IQR 61-79] years), of whom 87 (29%) had reduced LVEF. The final model showed moderate discrimination (AUC 0.71), sensitivity (0.67) and specificity (0.70). Including cardiac CT volumes in addition to baseline and AIF variables improved model fit (p=0.04). Conclusions Our model may aid risk stratification for reduced LVEF in AIS patients undergoing acute cardiac CT and could support identification of patients in whom additional TTE is warranted. Conflict of interest MMW received the Arthur Fonville Award for Stroke Research in 2025 for this work. SSN received travel grants from the Cultuurfondsbeurs, Remmert Adriaan Laan Fonds, CONTRAST consortium and Dr. Jan Meerwaldt Stichting outside the submitted work, JMC reports grants from Medtronic, Siemens, AstraZeneca and Bayer outside the submitted work (all paid to institution). JMC is shareholder and co-founder of TrianecT. CBM reports grants from Stryker and Boeringher-Ingelheim outside the submitted work (paid to institution) and is shareholder of Nicolab (minority interest). LAR was supported by a personal Dekker Junior Clinical Scientist Grant from the Dutch Heart Foundation.The other authors have no financial conflicts of interest.

Abstract Introduction Cardiac CT is increasingly used to screen for cardioembolism in stroke patients. We assessed the frequency and management of non-cardiac incidental findings on prospective ECG-gated cardiac CT in patients with a suspected stroke. Patients and methods This was a post-hoc analysis of the Mind the Heart study, a prospective single-centre cohort study including consecutive adult patients with acute ischaemic stroke (AIS), transient ischaemic attack (TIA), or a stroke mimic who underwent cardiac CT as part of an acute stroke imaging protocol. Endpoints were pre-defined non-cardiac incidental findings that were detected on cardiac CT: pulmonary embolism (PE), potential malignant lesions, pulmonary consolidations or ground-glass densities, bone fractures, lymphadenopathy, focal liver lesions, and ascending aortic or pulmonary artery dilatation. Change of management was defined as additional treatment or follow-up. Results We included 654 patients (57% men, median age 71 [IQR 59–80] years) of whom 451 (69%) had AIS, 48 had TIA (7%), and 155 had a stroke mimic (24%). Overall, 58 non-cardiac incidental findings were found in 55 (8%; 95%CI, 6–11) patients. The most frequent incidental findings were consolidations or ground-glass densities (n = 17, 3%), liver cysts or non-specific hypodensities (n = 14, 2%), pulmonary nodules or masses (n = 9, 1%), and PEs (n = 8, 1%). Incidental findings led to a change of management in 17/55 (31%) patients of whom 13/55 (24%) had additional follow-up and 9/55 (16%) received treatment (anticoagulation n = 8, chemotherapy n = 1). Discussion & Conclusion Non-cardiac incidental findings were observed on cardiac CT in 8% of patients with a suspected stroke. These findings changed management in 31% of these patients.

BACKGROUND: Left atrial (LA) diverticula are focal outpouchings of the LA wall and may increase ischemic stroke risk. We studied recurrent ischemic stroke in patients with acute ischemic stroke and LA diverticula detected on cardiac computed tomography. METHODS: We used data from a prospective cohort study of patients with acute ischemic stroke undergoing cardiac computed tomography acquired during the acute stroke imaging protocol. Cardiac radiologists systematically assessed the presence and characteristics of LA diverticula, defined as LA wall outpouchings with a length/ostium width ratio >0.5 and length ≥3 mm. We compared recurrent ischemic stroke and functional outcome (modified Rankin Scale) after 2 years between patients with and without LA diverticula, adjusting for age, history of atrial fibrillation and ischemic stroke, and anticoagulation use. RESULTS: Of 447 included patients (median age 72 [interquartile range (IQR), 62–81], 59% male), 126 (28%) had LA diverticula: median length 6 mm (IQR, 4–8), width 5 mm (IQR, 4–7), and volume 113 mm 3 (IQR, 52–254). There was no statistically significant difference in age (median 70 [IQR, 58–79] versus 73 [IQR, 63–81]; P =0.06), sex (64% versus 57% male; P =0.28), history of ischemic stroke (21% versus 17%; P =0.48), atrial fibrillation (11% versus 19%; P =0.09), or baseline National Institutes of Health Stroke Scale score (median 5 [IQR, 2–14] versus 5 [IQR, 3–14]; P =0.54) between patients with and without LA diverticula, respectively. Recurrent ischemic stroke was more common in patients with LA diverticula (18/124 [15%] versus 24/314 [8%], adjusted hazard ratio, 2.01 [95% CI, 1.08–3.77]), and recurrence risk increased with diverticulum volume (adjusted hazard ratio, 1.02 [95% CI, 1.01–1.03] per 10 mm 3 ). Functional outcome was better in patients with diverticula (median modified Rankin Scale score of 2 [IQR, 1–3] versus 3 [IQR, 1–6], adjusted common odds ratio, 0.62, [95% CI, 0.42–0.92]). CONCLUSIONS: LA diverticula are a common finding on cardiac computed tomography in patients with acute ischemic stroke, and the risk of recurrent ischemic stroke was increased in these patients, particularly in those with larger diverticula. Atrial diverticula may be a risk factor for recurrent ischemic stroke. REGISTRATION: URL: https://www.onderzoekmetmensen.nl/nl/trial/50352 ; Unique identifier: NL6413901818.

Abstract Background Patients with atrial fibrillation (AF) are at increased risk of stroke, often arising from a thrombus in the left atrial appendage (LAA). In selected cases, left atrial appendage occlusion or closure is an alternative for stroke prevention with oral anticoagulation. To assess the risk of stroke and the benefit of LAA closure and to select the appropriate device, it is crucial to quantify the morphology and dynamics of the left atrial appendage (LAA). To date, much about LAA dynamics in this setting is unknown, and subsequently the risk of embolic stroke and inappropriate device positioning is insufficiently explored. Purpose We describe the morphological and dynamic differences of the left atrium (LA) and LAA in high risk AF patients compared to controls undergoing trans catheter aortic valve implantation (TAVI). Methods Our study population consists of 14 patients, seven with AF and seven without AF, undergoing TAVI, since dynamic computed tomography (CT) angiography scans are performed in the standard of care in these patients. The scans were acquired every 5% of the cardiac cycle (i.e., R-R interval on the ECG) (Figure 1a). The LA and LAA were semi-automatically segmented (Figure 1b) to determine the following parameters across the entire cardiac cycle: LA volume; LAA volume, depth, height, and length; and ostium area, eccentricity, and diameter. Results AF patients had a significantly larger LA volume (108 mL vs 68 mL, p=0.03), while the LA volume change throughout the cardiac cycle was similar in AF patients and controls. Both groups had an LA volume change of 35mL on average. Figure 1cd shows the LA and LAA volume curves of a patient with and without AF. The LAA ostium size and volume of AF patients exhibited larger dynamic variations than those from non-AF patients, while the ostium eccentricity in AF patients showed less variation and the ostium shape was rounder. Conclusions We found differences in morphologic and dynamic parameters of the LA and LAA between AF and non-AF patients. The morphology and dynamics of the LAA can increase the understanding of LAA thrombus formation. Moreover, it may have implications for the risk of embolic stroke and may assist in the selection of the optimal LAA closure device type and size.

Limited data exist on clot composition and detailed characteristics of arterial thrombi associated with large vessel occlusion in acute ischemic stroke. Advances in endovascular thrombectomy and related imaging modalities have created a unique opportunity to analyze thrombi removed from cerebral arteries. Insights into thrombus composition, etiology, physical properties and neurovascular interactions may lead to future advancements in acute ischemic stroke treatment and improved clinical outcomes. Advances in imaging techniques may enhance clot characterization and inform therapeutic decision-making prior to treatment and reveal stroke etiology to guide secondary prevention. Current imaging techniques can provide some information about thrombi, but there remains much to evaluate about relationships that may exist among thrombus composition, occlusion characteristics and treatment outcomes. Improved pathophysiological characterization of clot types, their properties and how these properties change over time, together with clinical correlates from ongoing studies, may facilitate revascularization with thrombolysis and thrombectomy. Interdisciplinary approaches covering clinical, engineering and scientific aspects of thrombus research will be key to advancing the understanding of thrombi and improving acute ischemic stroke therapy. This consensus statement integrates recent research on clots and thrombi retrieved from cerebral arteries and provides a rationale for further analyses, including current opportunities and limitations.