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Review
. 2021 Jul;110(7):938-958.
doi: 10.1007/s00392-021-01834-x. Epub 2021 Jun 18.

Expert opinion paper on cardiac imaging after ischemic stroke

Renate B Schnabel  1   2   3 , Stephan Camen  1   2 , Fabian Knebel  4 , Andreas Hagendorff  5 , Udo Bavendiek  6 , Michael Böhm  7 , Wolfram Doehner  8   9   10 , Matthias Endres  9   10   11   12   13 , Klaus Gröschel  14 , Andreas Goette  3   15 , Hagen B Huttner  16 , Christoph Jensen  17   18 , Paulus Kirchhof  1   2   3   19 , Grigorios Korosoglou  20 , Ulrich Laufs  5 , Jan Liman  21 , Caroline Morbach  22 , Darius Günther Nabavi  23 , Tobias Neumann-Haefelin  24 , Waltraud Pfeilschifter  25   26 , Sven Poli  27   28 , Timolaos Rizos  29 , Andreas Rolf  30 , Joachim Röther  31 , Wolf Rüdiger Schäbitz  32 , Thorsten Steiner  29   33 , Götz Thomalla  34 , Rolf Wachter  5   35 , Karl Georg Haeusler  36   37
Affiliations
Review

Expert opinion paper on cardiac imaging after ischemic stroke

Renate B Schnabel et al. Clin Res Cardiol. 2021 Jul.

Abstract

This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.

Keywords: Cardiac imaging; Computed tomography; Echocardiography; Expert opinion; Ischemic Stroke; Magnetic resonance imaging; Transient ischemic attack.

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Conflict of interest statement

RBS has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme under the grant agreement No 648131, from the European Union’s Horizon 2020 research and innovation programme under the grant agreement No 847770 (AFFECT-EU) and German Center for Cardiovascular Research (DZHK e.V.) (81Z1710103); German Ministry of Research and Education (BMBF 01ZX1408A) and ERACoSysMed3 (031L0239). RBS has received speaker honoraria and consulting fees from BMS/Pfizer outside this work. FK reports lecture/advisory board fees from Novartis, Bracco, AstraZeneca, Bayer, Alnylam, Sanofi, Shire, Pfizer, Akcea, Canon, all outside this manuscript. UB reports lecture fees/advisory board fees from Abott, Alnylam, Amgen, Astra Zeneca, Novartis outside the submitted work and travel support from Amgen, Bayer, Berlin-Chemie and Pfizer. MB reports fees from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Servier, Medtronic, ReCor, Vifor, Novartis and Abbott. MB is supported by the Deutsche Forschungsgemeinschaft (DFG, TTR 219, S-01). ME reports grants from Bayer and fees paid to the Charité from Bayer, Boehringer Ingelheim, BMS, Daiichi Sankyo, Amgen, GSK, Sanofi, Covidien, Novartis, Pfizer, all outside the submitted work. HBH reports research grants by Novartis, Medtronic, UCB Pharma and Portola Pharmaceuticals. HBH reports personal fees from Bayer AG, Boehringer Ingelheim, Daiichi Sankyo, Medtronic, CLS Behring, UCB Pharma and Portola Pharmaceuticals. JL reports lecture fees/advisory board fees from Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb, Daiichi Sankyo, Stryker and Pfizer. CM reports research cooperation with the University of Würzburg and Tomtec Imaging Systems funded by a research grant from the Bavarian Ministry of Economic Affairs, Regional Development and Energy, Germany; advisory and speakers honoraria as well as travel grants from Amgen, Tomtec, Orion Pharma, Alnylam, AKCEA, Pfizer, and EBR Systems; principal investigator in trials sponsored by Alnylam and AstraZeneca; financial support from the interdisciplinary center for clinical research—IZKF Würzburg (advanced clinician-scientist program).WP received honoraria and lecture fees from Bayer Healthcare, Pfizer, Stryker neurovascular and research grants from Boehringer Ingelheim and Stryker neurovascular. SP received speaker’s/consulting honoraria from AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers-Squibb/Pizer, Daiichi Sankyo, and Werfen, reimbursement for congress traveling from Bayer, and Boehringer-Ingelheim, and research support from Bristol-Myers Squibb/Pizer, Boehringer-Ingelheim, Daiichi Sankyo, and Helena Laboratories (all outside of the present work). TR received consulting honoraria, speakers’ honoraria and travel support from Bristol-Myers Squibb/Pfizer, Boehringer-Ingelheim, Bayer HealthCare and DaichiiSankyo, outside the submitted work. AR reports lecture honoraria from Pfizer, Boehringer Ingelheim, Bayer, BMS, Berlin Chemie. JR reports lecture fees/advisory board fees from Bayer, Boehringer Ingelheim, BMS, Daiichi Sankyo, Amgen, Pfizer (unrelated to the submitted manuscript). WRS reports research grant Health Economic Research Zentrum, Ferrer. Speakers’ Bureau: Bristol-Myers Squibb, Boehringer Ingelheim, Daiichi Sankyo Co., Bayer, Pfizer, Medtronic, Ferrer as well as consultant/advisory board fees from Boehringer Ingelheim, Daiichi Sankyo Co., Medtronic. GT reports study grants by Bayer, lecture fees/advisory board fees from Acandis, Bayer, Boehringer Ingelheim, Bristol-Myers-Squibb / Pfizer, Daiichi Sankyo, and Stryker. RW reports grants from Bundesministerium für Bildung und Forschung (BMBF), Deutsches Zentrum für Herz-/Kreislaufforschung, Deutsche Forschungsgemeinschaft, European Union and Medtronic, all outside the submitted work. He received personal fees from AstraZeneca, Bayer, Berlin Chemie, Boehringer Ingelheim, Bristol-Myers-Squibb, CVRX, Daiichi Sankyo, Gilead, Medtronic Novartis, Pfizer, Pharmacosmos, Servier, outside the submitted work. KGH reports study grants by Bayer and Sanofi-Aventis, lecture fees/advisory board fees from Abbott, AstraZeneca, Bayer, Biotronik, Boehringer Ingelheim, Bristol-Myers-Squibb, Daiichi Sankyo, Edwards Lifesciences, Medtronic, Pfizer, Premier Research and Sanofi-Aventis. The other authors report no conflict of interest. Sollte formal vor den COIs von KGH aufgeführt werden.

Figures

Fig. 1
Fig. 1
Scheme of the different topographies of the ultrasound probes and example imaging planes to illustrate differences in the ability to visualize cardiac structures, modified from [35, 36]. Common potential sources of embolism (high risk—blue, minor/unclear—green) or indicators of cardiovascular disease (black) are shown. Further, less common potential sources of embolism and echocardiographic findings are provided in Table 1
Fig. 2
Fig. 2
Image acquisition transthoracic echocardiography protocol in post-stroke patients. Parasternal long axis view for measurements of left ventricular (LV) diameters, left ventricular outflow tract (LVOT) diameter, LV-wall thickness, dimensions of the aortic arch (a); parasternal short axis view at the level of the mitral valve (MV) for assessment of MV pathologies, detection or exclusion of MV stenosis or MV regurgitation (b); parasternal short axis view at the level of the aortic valve (AV) for assessment of AV pathologies, detection or exclusion of AV stenosis or AV regurgitation (c); parasternal short axis view at the level of the pulmonary valve (PV) and pulsed wave (pw) Doppler spectrum of the right ventricular (RV) outflow tract (RVOT) flow to assess RV stroke volume for pulmonary stroke volume (Qp)/ systemic stroke volume (Qs)—calculation (d); parasternal short axis view of the interatrial septum to detect or exclude atrial communication defects (e); apical long axis view for assessment of LV function using deformation imaging (f); color-coded apical long axis view for assessment of AV function including pw Doppler spectrum of the LVOT flow to assess LV stroke volume for Qp/Qs-calculation (g), if AV is pathological a continuous wave (cw) Doppler spectrum has to be added; color-coded apical long axis view for assessment of MV function including pw Doppler spectrum of the transmitral flow (h), if MV is pathological a cw Doppler spectrum has to be added; apical 2-chamber view for assessment of LV function using deformation imaging (i); apical 4-chamber view for assessment of LV function using deformation imaging (j); color-coded apical 4-chamber view for assessment of tricuspid valve function including cw Doppler spectrum to assess systolic pulmonary artery pressure (sPAP) (k); color-coded apical 4-chamber view of the interatrial septum to detect or exclude atrial communication defects (l); color-coded tissue Doppler apical 4-chamber view including tissue pw Doppler spectrum of the basal septal myocardial velocities (m); color-coded tissue Doppler apical 4-chamber view including tissue pw Doppler spectrum of the lateral septal myocardial velocities (n); subcostal view of the inferior caval vein to document systemic volume state (o); subcostal short axis view of the interatrial septum to detect or exclude atrial communication defects (p); subcostal short axis view at the level of the pulmonary valve and pw Doppler spectrum of the RVOT flow to assess RV stroke volume for Qp/Qs-calculation, if parasternal view is not possible (q); suprasternal view of the aortic arch to detect or exclude aortic dissection and other aortic pathologies (r). AV aortic valve, cw continuous wave, LV left ventricular, LVOT left ventricular outflow tract, MV mitral valve, pw pulsed wave, Qs systemic stroke volume, Qp pulmonary stroke volume, RV right ventricular, RVOT right ventricular outflow tract
Fig. 3
Fig. 3
Image acquisition transoesophageal echocardiography protocol in post-stroke patients. Midoesophageal 4-chamber view for assessment of LV function using deformation imaging, if documentation using transthoracic echocardiography (TTE) is not possible (a); midoesophageal 2-chamber view for assessment of LV function using deformation imaging, if TTE documentation is not possible (b); midoesophageal long-axis view for assessment of LV function using deformation imaging, if TTE documentation is not possible (c); conventional 2D-documentation at least in 2 different sectional planes of the interatrial septum (IAS) (d); color-coded 2D-documentation at least in 2 different sectional planes of the IAS to document interatrial communication defects (e); contrast 2D-documentation with agitated saline at least in 2 different sectional planes of the IAS to document patent foramen ovale (PFO). Ideally no or mild sedation of the patient is performed and the Valsalva maneuver practiced with the patient before administration of agitated saline contrast agent. If available, 3D transoesophageal probes should be used and the test repeated several times, if negative. Good documentation is necessary to distinguish inter-atrial from trans-pulmonary shunts (f); contrast 3D-documentation with agitated saline to document PFO, if possible (g); conventional 2D-documentation at least in 2 different sectional planes of the left atrial appendage (LAA) (h); color-coded 2D-documentation at least in 2 different sectional planes of the LAA to exclude or document LAA thrombus formation (i); pulsed wave (pw) Doppler spectrum of the LAA flow velocities (j); 3D-documentation of the LAA, if possible (k); conventional 2D-documentation of the long axis and short axis view of the aortic valve (AV) (l); color-coded 2D-documentation of the long axis and short axis view of the AV (m); 3D-documentation of the AV and the aortic root complex, if possible (n); color-coded 3D-documentation of the AV and the aortic root complex, if relevant AS or AR is present and if possible (o); conventional 2D-documentation of the long axis and short axis view of the mitral valve (MV) (p); color-coded 2D-documentation of the long axis and short axis view of the MV (q); 3D-documentation of the MV, if possible (r); color-coded 3D-documentation of the MV, if relevant MS or MR is present and if possible (s); conventional 2D-documentation of the descending aorta/aortic arch (t); 3D-documentation of the descending aorta/aortic arch, if possible (u). AR aortic valve regurgitation, AS aortic valve stenosis, AV aortic valve, IAS interatrial septum, LAA left atrial appendage, LV left ventricular, MR mitral valve regurgitation, MS mitral valve stenosis, MV mitral valve, PFO patent foramen ovale, pw pulsed wave, TTE transthoracic echocardiography
Fig. 4
Fig. 4
Expert-based recommendations for post-stroke imaging. Patients with (acute) ischemic stroke or TIA should receive transthoracic echocardiography (TTE) if either a cardiac cause of stroke is suspected or any cardiovascular risk factor is present. Transoesophageal echocardiography (TOE) should additionally be performed in patients with suspicious findings, insufficient image quality or if no cardiac source of stroke was detected despite clinical suspicion for cardioembolic stroke (†TTE and TOE in a single session is recommended if the cardiac source of stroke is suspected as indicated by the bold arrow). Inconclusive TTE or TOE and specific suspicion of cardiac disease may lead to further diagnostic work-up, e.g., contrast-enhanced echocardiography or cardiac magnetic resonance imaging. The value of different cardiovascular imaging methods for common cardiac pathologies is listed in Table 1
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