Detection and prevalence of left ventricular thrombus in patients with embolic stroke of undetermined source

Background: Embolic Stroke of Undetermined Source (ESUS) is defined as non-lacunar brain infarct without proximal arterial stenosis or known cardioembolic source (including atrial arrythmias). Little is known about the prevalence of left ventricular (LV) thrombus as a potential source of embolism in patients presenting with ESUS.

Objectives: We aimed to use contrast-enhanced cardiac computed tomography (CT) imaging to elucidate the prevalence of LV thrombus in patients suspected of ESUS.

Methods: We prospectively investigated 43 consecutive patients who presented to our hospital with ESUS between January 2019 and December 2019. All patients underwent 2D echocardiography and contrast-enhanced CT. In addition to the standard CT angiogram performed after contrast infusion, a second CT image was performed 90 seconds after contrast infusion.

Results: In our study population (73.6 ± 10.1 years, 44% [18/43] female), LV thrombus was detected in 9.3%, 4 out of 43 patients. Contrast enhanced CT detected LV thrombus in the apex in all cases, while only one case was also detected by 2D echocardiography. All cases were associated with significant coronary obstructive disease at the territory of left anterior descending

Other findings included left atrial thrombus (2 pt.), appendage thrombus (1 pt.), hypo-attenuating leaflet thickening (HALT) after transcatheter aortic valve replacement (TAVI) (1 pt.), significant aortic atherosclerosis (4 pt.), and 3 cases of pulmonary emboli (PE).

Conclusion: Contrast-enhanced CT may help improve detection of LV thrombus in patients presenting with ESUS and therefore provide relevant information for anticoagulation therapy and need of further coronary evaluation and intervention. The high prevalence of LV thrombus in ESUS patients make the use of complementary 3D imaging important.