Evaluation of causal heart diseases in cardioembolic stroke by cardiac computed tomography

Figures

• 

  Figure 1. Cardiac computed tomography images of left atrial appendage in patients with sinus rhythm and atrial fibrillation. A: Under normal sinus rhythm, left atrial appendage (LAA) is filled with contrast medium in early phase, which evaluates the coronary artery. Left: axial image; right: three-dimensional volume-rendered image; B: Under atrial fibrillation, axial early phase image shows triangular filling defect in LAA (left, asterisk). On delayed phase (right), LAA filling defect completely disappeared, which means the filling defect reflected blood stasis in LAA rather than thrombus.

• 

  Figure 2. Left atrial appendage thrombus. An 85-year-old woman with congestive heart failure and atrial fibrillation underwent cardiac computed tomography (CCT) in search of underlying heart disease. She suffered from acute ischemic stroke three months after CCT. A and B: Early phase CCT images (A: Axial; B: Sagittal) show multiple filling defects in left atrial appendage (LAA, arrow and arrowheads); C and D: Delayed phase CCT images (C: Axial; D: Sagittal) also show multiple filling defects in LAA (arrow and arrowheads) confirming multiple LAA thrombus; E: Diffusion-weighted brain magnetic resonance imaging shows hyperintense lesions in right temporoparietal lobe and left anterior limb of internal capsule (arrows).

• 

  Figure 3. Bilateral atrial thrombus. A 53-year-old man with atrial fibrillation and right renal infarction underwent cardiac computed tomography (CCT) in search of causal heart pathology of cardioembolism. A: Axial early phase CCT image shows filling defect in left atrial appendage (LAA, upper, asterisk). Axial delayed phase CCT image also shows filling defect in LAA confirming LAA thrombus (lower, arrow); B: Axial early phase CCT image shows filling defect in right atrial appendage (RAA, upper, asterisk). Axial delayed phase CCT image also shows filling defect in RAA confirming RAA thrombus (lower, arrowhead); C: Early phase CCT images (upper: Axial; lower: Sagittal) show filling defect in LA posterior wall, which suggests LA thrombus (black arrow).

• 

  Figure 4. Mitral stenosis. A 70-year-old man with mitral stenosis and atrial fibrillation underwent cardiac computed tomography (CCT) to rule out obstructive coronary artery disease. A and B: Left ventricular outflow tract long axis (A) and short axis (B) reformatted CCT images (upper: Mid systole at 20% of the R-R interval; lower: Mid diastole at 80% of the R-R interval) show thickened anterior and posterior mitral valve leaflets (arrowhead) and restricted mitral valve opening, representing mitral stenosis. Associated severe enlargement of left atrium is also found; C: Axial early phase CCT image shows triangular filling defect in left atrial appendage (LAA, upper, arrow). Axial delayed phase CCT image also shows filling defect in LAA confirming LAA thrombus (lower, arrow); D: Atrial functional analysis shows severely impaired LA function. LA end-systolic volume, end-diastolic volume, and ejection fraction were 180.3 mL, 166.3 mL, and 8%, respectively.

• 

  Figure 5. Left atrial appendage aneurysm. A 56-year-old man with atrial fibrillation (Af) underwent cardiac computed tomography (CCT) to rule out obstructive coronary artery disease before catheter ablation for Af. A and B: Axial (A) and sagittal (B) reformatted CCT images show enlarged left atrial appendage (LAA, arrow) with triangular filling defect inside. LAA orifice diameter, body width, and length were 3.4 cm, 5.2 cm, and 6.8 cm, respectively; C: Three-dimensional volume-rendered image of CCT shows LAA aneurysm. CCT-derived maximum LAA volume was 56 mL.

• 

  Figure 6. Left ventricular thrombus complicated with anteroseptal myocardial infarction. An 80-year-old man hospitalized with acute ischemic stroke underwent cardiac computed tomography (CCT) to rule out obstructive coronary artery disease. A: Diffusion-weighted brain magnetic resonance imaging shows hyperintense lesions in right thalamus and right posterior limb of internal capsule (arrow); B and C: Horizontal long axis (B) and vertical long axis (C) reformatted CCT images show round-shaped thrombus in left ventricular apex (arrow); D: Soap-bubble maximum intensity projection reconstruction image of whole coronary artery shows total occlusion of left anterior descending coronary artery (LAD, arrow) and right coronary artery (RCA, arrowhead); E: Polar map of left ventricular wall motion shows severely reduced anterior to anteroseptal wall motion perfused by LAD (arrowheads). LCX: left circumflex coronary artery.

• 

  Figure 7. Left ventricular noncompaction. A 60-year-old man with congestive heart failure underwent cardiac computed tomography (CCT) in search of underlying heart disease. A–C Horizontal long axis (A), vertical long axis (B), and short axis (C) reformatted CCT images show increased trabeculations from mid to apical portion of left ventricle (arrows). Noncompacted-to-compacted layer ratio at end-diastolic was 2.6. Note contrast heterogeneity within left atrial appendage (LAA), which reflects blood stasis in LAA (arrowhead); D: Left ventricular (LV) functional analysis shows impaired LV function. LV end-diastolic volume, end-systolic volume, and ejection fraction were 191.1 mL, 121.5 mL, and 36%, respectively.

• 

  Figure 8. Left ventricular apical thrombus complicated with mid-ventricular obstructive hypertrophic cardiomyopathy. A 56-year-old man with unsustained ventricular tachycardia underwent cardiac computed tomography (CCT) in search of underlying heart disease. A and B: Horizontal long axis (A) and vertical long axis (B) reformatted CCT images at end diastole show partially calcified round-shaped thrombus in left ventricular apex (arrow). C and D: Horizontal long axis (C) and vertical long axis (D) reformatted CCT images at end systole show mid-ventricular hypertrophy and mid-cavitary obliteration of left ventricle (arrowhead) with thin-walled left ventricular apical aneurysm; E and F: Horizontal long axis (E) and vertical long axis (F) reformatted images of delayed enhanced cardiac magnetic resonance imaging show transmural late gadolinium enhancement in mid to apical portion of left ventricle (arrowheads).

• 

  Figure 9. Interventricular membranous septal aneurysm. A 78-year-old man underwent cardiac computed tomography (CCT) to further evaluate pathologic outpouching from the left ventricular outflow tract (LVOT) observed on transthoracic echocardiography. A–C: Axial (A), horizontal long axis (B), and sagittal (C) reformatted CCT images show multi-lobular outpouching projecting into right ventricle from LVOT (arrows) consistent with interventricular membranous septal aneurysm (IVMSA), with no evidence of a shunt. Note contrast heterogeneity within IVMSA, which reflects blood stasis in IVMSA.

• 

  Figure 10. Atrial myxoma. A 76-year-old man hospitalized with acute ischemic stroke underwent cardiac computed tomography (CCT) to further evaluate a left atrial mass observed on transthoracic echocardiography. A: Diffusion-weighted brain magnetic resonance imaging shows hyperintense lesions in bilateral cerebellar hemisphere, pons, splenium of corpus callosum, and bilateral occipital lobe (arrows); B–D: Axial (B), horizontal long axis (C), and short axis (D) reformatted CCT images show a 31-mm-sized lobulated left atrial mass attached to the interatrial septum (arrows). He had a previous history of chronic aortic dissection (asterisk). Urgent surgical mass resection was performed. Histological examination confirmed cardiac myxoma.

• 

  Figure 11. Gradually increased atrial myxoma. An 80-year-old man with chest pain underwent cardiac computed tomography (CCT) to evaluate obstructive coronary artery disease. CCT showed severe stenosis in the left anterior descending coronary artery, and percutaneous coronary intervention was performed. Simultaneously, CCT incidentally demonstrated a left atrial mass that could not be visualized on transthoracic echocardiography. A: Axial (upper) and horizontal long axis (lower) reformatted CCT images show left atrial mass of 7 mm by 5 mm in diameter attached to interatrial septum (arrows); B: Axial (upper) and horizontal long axis (lower) reformatted CCT images performed one year later show increased mass size of 11 mm by 11 mm in diameter. Subsequently, elective surgical mass resection was performed. Histological examination confirmed cardiac myxoma.

• 

  Figure 12. Infective endocarditis. A 73-year-old man hospitalized with infective endocarditis and acute ischemic stroke underwent cardiac computed tomography (CCT) to rule out obstructive coronary artery disease before urgent surgical aortic valve replacement. A: Diffusion-weighted brain magnetic resonance imaging shows hyperintense lesions in bilateral cerebral hemisphere (arrows). B: Left ventricular outflow tract long axis reformatted CCT image shows irregularly shaped aortic valve vegetations adherent to left coronary cusp (LCC); C: Surgically resected LCC of aortic valve with fragile vegetations. NCC: Noncoronary cusp.