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. 2025 Sep;56(9):2561-2570.
doi: 10.1161/STROKEAHA.125.051199. Epub 2025 Jul 7.

Left Atrial Diverticula Detected on Cardiac CT in Patients With Acute Ischemic Stroke: A Substudy of Mind the Heart

Shan Sui Nio  1 , Leon A Rinkel  1 , Olivia N Cramer  1 , Z Beyda Özata  1 , Chiel F P Beemsterboer  1 , Valeria Guglielmi  1 , Berto J Bouma  2 , S Matthijs Boekholdt  2 , Nick H J Lobé  3 , Ludo F M Beenen  3 , Nerea Arrarte Terreros  3   4   5 , Henk A Marquering  3   4 , Charles B L M Majoie  3 , Yvo B W E M Roos  1 , Adrienne van Randen  3 , R Nils Planken #  6 , Jonathan M Coutinho #  1
Affiliations

Left Atrial Diverticula Detected on Cardiac CT in Patients With Acute Ischemic Stroke: A Substudy of Mind the Heart

Shan Sui Nio et al. Stroke. 2025 Sep.

Abstract

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 mm3 (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 mm3). 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.

Keywords: anticoagulants; diverticulum; heart atria; ischemic stroke; risk factors; tomography.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and publication of this article: Dr Bouma has received grants from Abbott Fund. Dr Majoie has received research grants from CVON/Dutch Heart Foundation, European Commission, Healthcare Evaluation the Netherlands, Stryker Corporation and Boehringer Ingelheim (paid to institution). Drs Majoie, Marquering, and Roos are shareholders of Nicolab, a company that focuses on the use of artificial intelligence for medical image analysis. Dr Coutinho reports grants from Medtronic, Siemens, AstraZeneca, and Bayer outside the submitted work (paid to institution). Dr Coutinho has received compensation from Portola Pharmaceuticals, LLC, for consultant services (paid to employer). Dr Coutinho is shareholder for Founder. Drs Coutinho and Marquering are shareholders of TrianecT. Dr Terreros and Marquering are cofounders and shareholders of inSteps. The other authors report no conflicts.

Figures

Figure 1.
Figure 1.
Axial images of acute cardiac computed tomography portraying left atrial diverticula. A, Right superior location with a cystic shape, (B) left superior location with a cystic shape, (C) right inferior location with cystic shape, (D) trabeculated endocardial surface (E) tubular shape (F) right superior location with hypodensity within outpouching, suggesting slow-flow (Hounsfield units >100).
Figure 2.
Figure 2.
Flowchart of included patients. CT indicates computed tomography.
Figure 3.
Figure 3.
Survival analysis between left atrial (LA) diverticula and recurrent stroke. Cox regression analysis of LA diverticula vs no LA diverticula (adjusted hazard ratio, 2.01 [95% CI, 1.08–3.77]; P=0.03). We corrected for the following potential confounders: age, history of atrial fibrillation, history of ischemic stroke, and anticoagulation use at baseline.
See this image and copyright information in PMC

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