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

Q: What are the key findings of this study?

Cardiovascular MRI had a lower diagnostic yield than transesophageal echocardiography for persistent foramen ovale in stroke patients (29.3% vs 53.7%, P<0.001), but higher yield for LV thrombus in non-stroke patients (28.1% vs 16.0%, P<0.001).

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Acute ischemic stroke and non-stroke populations undergoing evaluation for cardioaortic sources of embolism (n=2525). Intervention: Cardiovascular MRI (CMR) vs. Transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE). Primary outcome: Diagnostic yield (proportion of patients with a specific prespecified pathology on CMR or echocardiography), specifically persistent foramen ovale (PFO) detection in stroke patients (p=<0.001).

Q: What does this research mean for the field?

Cardiovascular MRI and echocardiography have similar diagnostic yields for most cardioaortic sources of embolism, but MRI has a lower yield for persistent foramen ovale in stroke patients and a higher yield for left ventricular thrombus in non-stroke patients. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To compare the diagnostic yield of cardiovascular MRI and echocardiography in identifying structural cardioaortic sources of embolism in patients with ischemic stroke.

Thomas R. Meinel; Angela Eggimann; Kristina Brignoli; Kerstin Wustmann; Eric Buffle; Felix G. Meinel; Jan F. Scheitz; Christian H. Nolte; Christoph Gräni; Urs Fischer; Johannes Kaesmacher; David Seiffge; Christian Seiler; Simon Jung

doi:10.3389/fneur.2021.699838

July 30, 2021Frontiers in NeurologyOpen Access

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

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Key result

CMR shows ~24-point lower diagnostic yield than TEE for PFO in stroke patients.

P<0.001
n=2,525

Figures

Why the study?

To compare the diagnostic yield of echocardiography and cardiovascular MRI to detect structural sources of embolism in patients with ischemic stroke and non-stroke populations.

Does cardiovascular MRI improve the diagnostic yield for structural cardioaortic sources of embolism compared to echocardiography in patients with acute ischemic stroke and non-stroke populations?

Key Points

To compare the diagnostic yield of cardiovascular MRI and echocardiography in identifying structural cardioaortic sources of embolism in patients with ischemic stroke.
Study quality and risk of bias were independently evaluated by two reviewers using the QUADAS-2 tool.
Cardiovascular MRI had a significantly lower diagnostic yield than transesophageal echocardiography for detecting persistent foramen ovale in stroke patients (29.3% vs. 53.7%, P < 0.001; 5 studies).
Left ventricular thrombus detection did not differ between modalities in stroke populations (CMR 5.0% vs. echo 3.2%, P = 0.8460; 4 studies), but cardiovascular MRI showed higher yield in non-stroke populations (28.1% vs. 16.0%, P < 0.001; 10 studies).
Diagnostic yields between cardiovascular MRI and echocardiography were similar for complex aortic plaques (16.3% vs. 18.6%, P = 0.5546) and left atrial thrombi (0.5% vs. 2.0%, P = 0.8791).

Study Design

Type

Meta-Analysis (n=2,525)

Multicenter

Yes

Structured PICO

Does cardiovascular MRI improve the diagnostic yield for structural cardioaortic sources of embolism compared to echocardiography in patients with acute ischemic stroke and non-stroke populations?

P

Population

2,525 adult patients (>16 years) across 27 single-center cohort studies (11 exclusively in acute ischemic stroke and 16 in non-stroke populations with known cardiac pathologies) who underwent both CMR and echocardiography.

I

Intervention

Cardiovascular magnetic resonance imaging (CMR), with or without contrast enhancement, as an index diagnostic test for structural cardioaortic sources of embolism

C

Comparator

Echocardiography as reference standard (12/27 studies used transesophageal echocardiography [TEE], 11/27 used transthoracic echocardiography [TTE], and 4/27 used both; time interval between CMR and echocardiography ranged from 0 to 89 days)

O

Outcome

Diagnostic yield, defined as the proportion of patients identified with a specific prespecified structural cardioaortic pathology (persistent foramen ovale, complex aortic plaques, left ventricular thrombus, left atrial/appendage thrombus, valvular vegetation, and non-thrombotic masses) on CMR vs. echocardiographysurrogate

Main Result

Absolute Event Rate: 29.3% vs 53.7%

p-value: p=<0.001

CMR and echocardiography have similar diagnostic yields for most structural cardioaortic sources of stroke except PFO (where TEE is superior) and LV thrombus in non-stroke cohorts (where CMR is superior), though randomized diagnostic trials are needed to establish whether routine CMR alters clinical outcomes.

Limitations

Included studies represented heterogeneous, highly selected populations with moderate to high risk of bias.
Lack of a true gold standard for many cardioaortic sources of embolism and unclear definitions for several pathologies.
Data were lacking to support evidence-based changes in clinical management or improved clinical outcomes based on imaging findings.
Most studies used TTE rather than TEE, limiting conclusions regarding TEE comparison.
Long or unclear time intervals (0 to 89 days) between CMR and echocardiography in several studies.
Included studies represented heterogeneous, highly selected populations with moderate to high risk of bias on QUADAS-2 assessment
Missing true gold standard and unclear definitions for many cardioaortic sources of embolism
Lack of data demonstrating evidence-based changes in management or clinical outcome benefits from diagnostic findings
Most studies used TTE rather than TEE, hampering conclusions for TEE
Long intervals between CMR and echocardiography (up to 89 days, unclear in 5/27 studies) and non-random sequence of testing

Implication

May guide modality selection in embolism workup; leaves open whether CMR alters clinical outcomes versus echocardiography.

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.

Discussion

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Cite This Study

Meinel et al. (2021) conducted a meta-analysis in Acute ischemic stroke and non-stroke populations undergoing evaluation for cardioaortic sources of embolism (n=2,525). Cardiovascular MRI (CMR) vs. Transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE) was evaluated on Diagnostic yield (proportion of patients with a specific prespecified pathology on CMR or echocardiography), specifically persistent foramen ovale (PFO) detection in stroke patients (p=<0.001). Cardiovascular MRI had a lower diagnostic yield than transesophageal echocardiography for persistent foramen ovale in stroke patients (29.3% vs 53.7%, P<0.001), but higher yield for LV thrombus in non-stroke patients (28.1% vs 16.0%, P<0.001).

synapsesocial.com/papers/6a7480de4d25a845ca09080e https://doi.org/10.3389/fneur.2021.699838

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

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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