Is it necessary to perform both Computed Tomography Angiography (CTA) and echocardiography (echo) in all stroke patients?

Imaging Requirements for Stroke Patients: CTA and Echocardiography

Not all stroke patients require both CT angiography (CTA) and echocardiography (echo); imaging should be tailored based on clinical presentation, with CTA recommended for all acute stroke patients while echocardiography should be performed selectively when a cardiac source is suspected.

Initial Imaging for Acute Stroke Patients

• All patients with suspected acute stroke must undergo immediate non-contrast brain CT imaging and vascular imaging with CTA including extracranial and intracranial arteries to guide hyperacute care 1
• CTA should be performed at the time of brain CT to assess both extracranial and intracranial circulation, ideally including "aortic arch-to-vertex" imaging 1
• CTA is essential for visualizing the intracranial circulation, posterior circulation, and aortic arch to identify stroke etiology and guide management decisions 1
• For patients eligible for acute stroke treatments, advanced CT imaging should be performed without substantially delaying thrombolysis or endovascular therapy 1

Role of Echocardiography in Stroke Patients

• Echocardiography should not be performed routinely in all stroke patients but should be reserved for specific clinical scenarios 1

• Echocardiogram should be performed in patients where a cardiac cause of stroke is suspected, including 1:

  • Young adults and children who present with stroke
  • Cases where infectious endocarditis is suspected
  • When the stroke mechanism has not been identified through other investigations

• The diagnostic yield of echocardiography varies significantly by age, with numbers needed to test increasing from 6 in patients younger than 50 years to 62 in patients aged 70 years and older 2

Cardiac Monitoring and Investigation

• All stroke patients should undergo an electrocardiogram (ECG) to assess baseline cardiac rhythm and provide information regarding structural heart disease 1
• In cases where ECG or initial cardiac rhythm monitoring does not show atrial fibrillation but a cardioembolic mechanism is suspected, prolonged ECG monitoring (up to 30 days) is recommended 1

Imaging Selection Based on Clinical Scenario

• For patients within acute treatment windows (0-4.5 hours), the primary goal is to exclude hemorrhage and assess ischemic changes, with non-contrast CT being the fastest initial modality 3
• For patients outside standard treatment windows, more advanced imaging can identify salvageable tissue and may help select patients for late reperfusion therapy 3
• When selecting between imaging modalities (CTA, MRA, or carotid ultrasound), decisions should be based on immediate availability and patient characteristics 1

Common Pitfalls to Avoid

• Delaying treatment with IV thrombolysis while waiting for advanced imaging is a critical error - if the patient is within the treatment window and has no contraindications on non-contrast CT, treatment should be initiated without waiting for additional imaging 3
• Performing routine echocardiography in all stroke patients leads to a high rate of non-specific findings in older patients, resulting in unnecessary testing 2
• Failing to perform echocardiography in younger stroke patients (under 50) where the diagnostic yield is much higher 2, 4

Recommended Approach to Stroke Imaging

1. For all acute stroke patients: Perform immediate non-contrast CT and CTA 1

2. For suspected cardioembolic source: Perform echocardiography when 1:

   • Patient is young (under 50 years)
   • No other stroke etiology is identified
   • Clinical features suggest cardioembolic mechanism
   • Infectious endocarditis is suspected

3. For cardiac monitoring: Perform ECG in all patients, with extended monitoring when cardioembolic mechanism is suspected despite normal initial ECG 1

By following this evidence-based approach, clinicians can optimize diagnostic efficiency while ensuring appropriate care for stroke patients.