Korean J Radiol.  2018 Oct;19(5):905-915. 10.3348/kjr.2018.19.5.905.

Diagnostic Accuracy of Electrocardiogram-Gated Thoracic Computed Tomography Angiography without Heart Rate Control for Detection of Significant Coronary Artery Stenosis in Patients with Acute Ischemic Stroke: A Comparative Study

• Song I
• Kang JH
• Kim MY
• Hwang HK
• Kim HY
• Ko SM

• KMID: 2418554
• DOI: http://doi.org/10.3348/kjr.2018.19.5.905

Abstract

OBJECTIVE
To compare the diagnostic performance of electrocardiogram (ECG)-gated thoracic computed tomography angiography (TCTA) without heart rate (HR) control in ischemic stroke patients with coronary CTA (CCTA) in non-stroke patients for detection of significant coronary artery stenosis.
MATERIALS AND METHODS
From September 2009 through August 2014, we retrospectively enrolled 138 consecutive patients diagnosed with acute ischemic stroke who had undergone ECG-gated TCTA and conventional coronary angiography (CCA). Over the same period, we selected 167 non-stroke patients with suspected or known coronary artery disease who had undergone CCTA and CCA. With CCA as the reference standard, the diagnostic performance of TCTA and CCTA for identification of significant coronary stenosis (diameter reduction ≥ 50%) was calculated.
RESULTS
There was no significant difference in baseline characteristics between TCTA (n = 132) and CCTA (n = 164), except for the higher prevalence of atrial fibrillation in the stroke group. There was significant difference (p < 0.001) between TCTA and CCTA in average HR (68 ± 12 vs. 61 ± 10 beats per minute) and image quality score (1.3 ± 0.6 vs. 1.2 ± 0.6). Significant coronary stenosis was identified in 101 (77%) patients, 179 (45%) vessels, and 293 (15%) segments of stroke patients, and in 136 (83%) patients, 259 (53%) vessels, and 404 (16%) segments of non-stroke patients. Diagnostic performance on a per-vessel and per-patient basis was similar in both TCTA and CCTA groups. There was only significant difference in area under receiver-operating characteristic curve between TCTA and CCTA groups (0.79 vs. 0.87, p < 0.001) on per-segment basis.
CONCLUSION
Electrocardiogram-gated TCTA without HR control facilitates the identification of significant coronary stenosis in patients with ischemic stroke.

Keyword

Atherosclerosis; Coronary artery disease; Coronary angiography; Computed tomography; Stroke

MeSH Terms

Angiography*
Atherosclerosis
Atrial Fibrillation
Coronary Angiography
Coronary Artery Disease
Coronary Stenosis*
Coronary Vessels*
Electrocardiography
Heart Rate*
Heart*
Humans
Prevalence
Retrospective Studies
Stroke*

Figure

• 

  Fig. 1 Protocol for TCTA.After coronary calcium scan, TCTA was acquired from aortic arch to inferior border of heart to detect significant coronary stenosis and high-risk sources of cardiogenic embolism, and to evaluate aortic plaques. Three minutes after TCTA, late-phase CT was acquired from left atrium to middle of left ventricle to distinguish between slow flow and thrombus in LAA without additional use of iodinated contrast medium. ECG = electrocardiogram, LAA = left atrial appendage, TCTA = thoracic computed tomography angiography

• 

  Fig. 2 Images in 70-year-old man with acute ischemic stroke.Patient manifested hypertension, diabetes mellitus and atrial fibrillation. A. ECG obtained during TCTA examination showed atrial fibrillation and ventricular premature contraction. ECG-based tube current modulation was switched off in this patient. B. Curved multi-planar reformatted image shows approximately insignificant stenosis (arrowhead) via mixed calcified and non-calcified plaques and poor contrast enhancement (arrow) in PL. C. Curved multi-planar reformatted image shows poor contrast enhancement in middle segment of LAD (arrows), corresponding to non-evaluable segment. D. Curved multi-planar reformatted image shows poor contrast enhancement or diffuse obstruction in OM1 (arrows). Patient was diagnosed with 3-vessel disease by TCTA findings. E. Early-phase TCTA demonstrates triangular-shape filling defects within LAA (arrows). F. Delayed imaging reveals complete in-filling of appendage confirming that defect was secondary to circulatory stasis rather than thrombus. G. Oblique sagittal reconstruction image of aortic arch shows 3.5-mm-thick atheroma (arrow) of proximal aortic arch with hypoattenuating component. H–J. Conventional coronary angiography images showed no significant stenoses in early-branching PL (arrow, H) and middle LAD (arrow, I) whereas subtotal occlusion without collateral flow in OM1 (arrow, J). LAD = left anterior descending coronary artery, OM1 = first obtuse marginal artery, PL = posterolateral branch

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