ExtendeD computed tomogrAphy angiographY for the successfuL DIaGnosis of cardioaortic tHrombus in Acute Ischemic stroke and TIA (DAYLIGHT): Study Protocol for a Randomized Controlled Trial.

INTRODUCTION: Cardiac imaging is one of the main components of the etiological investigation of ischemic strokes. However, basic and advanced cardiac imaging remain underused in most stroke centers globally. Computed tomography angiography (CTA) of the supra-aortic and intracranial arteries is the most frequent imaging modality applied during the evaluation of patients with acute ischemic stroke to identify the presence of a large vessel occlusion. Recent evidence from retrospective observational studies has shown a high detection of cardiac thrombi, ranging from 6.6 to 17.4%, by extending the CTA a few cm below the carina to capture cardiac images. However, this approach has never been prospectively compared against usual care in a randomized controlled trial. The DAYLIGHT (ExtendeD computed tomogrAphy angiographY for the successfuL DIaGnosis of cardioaortic tHrombus in Acute Ischemic stroke and TIA) prospective, randomized, controlled trial will evaluate whether an extended CTA (eCTA) + standard of care stroke workup results in higher detection rates of cardiac and aortic source of embolism compared to standard CTA (sCTA) + standard of care stroke workup. METHODS: DAYLIGHT is a single-center, prospective, randomized, open blinded end-point trial, aiming to recruit 830 patients with suspected acute ischemic stroke or transient ischemic attack (TIA) being assessed under acute code stroke at the Emergency Department or at a dedicated urgent stroke prevention clinic. Patients will be randomized 1:1 to eCTA vs sCTA. The eCTA will expand image acquisition caudally, 6 cm below the carina. All patients will receive standard of care cardiac imaging and diagnostic stroke workup. The primary efficacy endpoint will be the diagnosis of a cardioaortic thrombus after at least 30 days of follow-up. The primary safety endpoint will be door-to-CTA completion. The diagnosis of a qualifying ischemic stroke or TIA will be independently adjudicated by a stroke neurologist, blinded to the study arm allocation. Patients without an adjudicated ischemic stroke or TIA will be excluded from the analysis. The primary outcome events will be adjudicated by a board-certified radiologist with subspecialty training in cardio-thoracic radiology and a cardiologist with formal training in cardiac imaging. The primary analysis will be performed according to the intention-to-diagnose principle and without adjustment by logistic regression models. Results will be presented with odds ratios and 95% confidence intervals Conclusion. The DAYLIGHT trial will provide evidence on whether extending a CTA 6 cm below the carina results in an increased detection of cardio-aortic thrombi compared to standard of care stroke workup. CLINICALTRIALS: gov registration: NCT05522244.

Role of myocardial strain imaging in diagnosing inducible myocardial ischemia with treadmill contrast-enhanced stress echocardiography.

INTRODUCTION: The aim of this study is to analyze the diagnostic value of global longitudinal strain (GLS) in detecting inducible myocardial ischemia in patients with chest pain undergoing treadmill contrast-enhanced stress echocardiography (SE). METHODS: We retrospectively enrolled all patients who underwent invasive coronary angiography after treadmill contrast-enhanced SE. Rest and peak-stress myocardial GLS, segmental LS, and LS of 4-chamber (CH), 2-CH, and 3-CH views were reported. Luminal stenosis of more than 70% or fractional flow reserve (FFR) of < 0.8 was considered significant. RESULTS: In total 33 patients were included in the final analysis, among whom sixteen patients (48.4%) had significant coronary artery stenosis. Averaged GLS, 3-CH, and 4-CH LS were significantly lower in patients with critical coronary artery stenosis compared to those without significant stenosis (-17.1 ± 7.1 vs. -24.2 ± 7.2, p = 0.041), (-18.2 ± 8.9 vs. -24.6 ± 8.2, p = 0.045) and (-14.8 ± 6.2 vs. -22.8 ± 7.8, p = 0.009), respectively. Receiver operating characteristic (ROC) analysis of ischemic and non-ischemic segments demonstrated that a cut-off value of -20% of stress LS had 71% sensitivity and 60% specificity for ruling out inducible myocardial ischemia (Area under the curve was AUC = 0.72, P < 0.0001). CONCLUSION: Myocardial LS measured with treadmill contrast-enhanced stress echocardiography demonstrates potential value in identifying patients with inducible myocardial ischemia.

Aggressive Cholesterol Pericarditis With Minimal Effusion Masquerading as Treatment-Refractory Autoimmune Disease.

A middle-aged woman with rheumatoid arthritis presented with treatment-refractory pericarditis. Symptoms persisted despite escalation of immunosuppression, and she had recurrent admissions for heart failure. Imaging revealed minimal pericardial effusion and a thickened pericardium. Invasive hemodynamics confirmed constrictive physiology, and a pericardiectomy was required. Pathology testing confirmed cholesterol pericarditis, a rare condition of inflammatory cholesterol deposits within the pericardium. Previous reports describe moderate-to-large volumes of gold-coloured pericardial fluid. This case illustrates that cholesterol pericarditis can present with minimal pericardial effusion and rapidly progress to pericardial constriction.

Une femme d'âge moyen atteinte d'arthrite rhumatoïde a présenté une péricardite réfractaire. Les symptômes ont persisté en dépit de l'escalade de l'immunodépression. Elle a été admise de façon répétitive en raison d'insuffisance cardiaque. L'imagerie a révélé un épanchement péricardique minimal et un péricarde épaissi. L'exploration hémodynamique invasive a permis de confirmer la physiologie constrictive. Une péricardectomie a été nécessaire. L'examen pathologique a permis de confirmer la péricardite cholestérolique, une affection inflammatoire rare due aux dépôts de cholestérol dans le péricarde. Les observations précédentes décrivent des volumes modérés à élevés de liquide péricardique doré. Ce cas illustre que la péricardite cholestérolique peut se traduire par un épanchement péricardique minimal et progresser rapidement vers la péricardite constrictive.