Cardiovascular MRI Compared to Echocardiography to Identify Cardioaortic Sources of Ischemic Stroke: A Systematic Review and Meta-Analysis

Abstract

Background: To compare the diagnostic yield of echocardiography and cardiovascular MRI (CMR) to detect structural sources of embolism, in patients with ischemic stroke with a secondary analysis of non-stroke populations.Methods and Results: We searched MEDLINE/Embase (from 01.01.2000 to 24.04.2021) for studies including CMR to assess prespecified sources of embolism. Comparison included transthoracic and/or transesophageal echocardiography. Two authors independently screened studies, extracted data and assessed bias using the QUADAS-2 tool. Estimates of diagnostic yield were reported and pooled. Twenty-seven studies with 2,525 patients were included in a study-level analysis. Most studies had moderate to high risk of bias. Persistent foramen ovale, complex aortic plaques, left ventricular and left atrial thrombus were the most common pathologies. There was no difference in the yield of left ventricular thrombus detection between both modalities for stroke populations (4 studies), but an increased yield of CMR in non-stroke populations (28.1 vs. 16.0%, P < 0.001, 10 studies). The diagnostic yield in stroke patients for detection of persistent foramen ovale was lower in CMR compared to transoesophageal echocardiography (29.3 vs. 53.7%, P < 0.001, 5 studies). For both echocardiography and CMR the clinical impact of the management consequences derived from many of the diagnostic findings remained undetermined in the identified studies.Conclusions: Echocardiography and CMR seem to have similar diagnostic yield for most cardioaortic sources of embolism except persistent foramen ovale and left ventricular thrombus. Randomized controlled diagnostic trials are necessary to understand the impact on the management and potential clinical benefits of the assessment of structural cardioaortic stroke sources.Registration: PROSPERO: CRD42020158787.

Patent Foramen Ovale Management for Secondary Stroke Prevention: State-of-the-Art Appraisal of Current Evidence

“…In a recent meta-analysis including 5 studies and 236 patients, CMRI showed a 29.3% (95% CI, 23.6%–35.0%) detection yield compared with 53.7% (95% CI, 47.4%–59.9%) for TEE ( P <0.001). 26 Despite its relatively low diagnostic yield for PFO, CMRI may still be useful for understanding the role of right atrial flow patterns on the risk of paradoxical embolism. However, its current use remains investigational.…”

Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review

“…When comparing the two, cardiac CT and CMR have comparable diagnostic performance in visualising LA appendage thrombus and high-grade valve disease/calcifications, with both being inferior to TOE in imaging valvular AF, mitral valve prolapse, and highgrade valve disease/calcifications [62]. Cardiac CT is superior to CMR in terms of imaging aortic dissection, aortic aneurysm, and complex aortic plaques [62].…”

Elevation of cardiac biomarkers in stroke is associated with pathological findings on cardiac MRI—results of the HEart and BRain interfaces in Acute Stroke study

“…7 However, CMR is not a part of the routine diagnostic work-up in AIS patients and its availability is limited. 4,8 Moreover, data concerning the diagnostic value of CMR in patients with elevated cardiac biomarkers in the context of AIS is very scarce.…”

“…3 Different cardiac pathologies may be identified by performing cardiac magnetic resonance imaging (CMR). 4 CMR is recommended for the evaluation of a variety of cardiac conditions including cardiomyopathies, myocarditis, cardiac masses, cardiac thrombi, or pericardial diseases. 5 In addition, by examining the presence and pattern of late-gadolinium enhancement (LGE), one can distinguish lesions consistent with (chronic) myocardial infarction from nonischemic lesions.…”