Hyperacute Incidental Late Myocardial Enhancement in Ischemic Stroke Using Chest Spectral CT: Relationship with Etiology.

BACKGROUND: Hyperacute cardiac imaging of patients with acute ischemic stroke (AIS), though desirable, is impractical. Using delayed-enhancement, low-dose, non-gated, chest spectral computed tomography scans (DESCT), we explored the prevalence and patterns of incidental myocardial late iodine enhancement (LIE) and embolic sources, and their relationship with stroke etiology. METHODS: Since July 2020, DESCT was performed after cerebrovascular CT angiography (CTA) among patients with suspected AIS undergoing CT using a dual-layer spectral scanner, without additional contrast administration. Images were analyzed using monoenergetic reconstructions and iodine density maps, and the myocardial extracellular volume fraction (ECV, %) was calculated. RESULTS: Eighty patients with AIS were included. DESCT identified a cardiac thrombi in 6 patients (7.5%), and a complex aortic plaque in 4 (5%) cases; reclassifying 5 embolic strokes of uncertain source (28% of ESUS) to cardioembolic (CE, n = 3) and non-CE (n = 2) etiologies. LIE was identified in 38 (48%) patients, most commonly (82%) of ischemic pattern. We did not identify significant relationships between AIS etiology and the presence, pattern, and extent of LIE (p > 0.05); ECV (p = 0.56), severe aortic (p = 0.25) or valvular (p = 0.26) disease, or the extent of coronary calcification (p = 0.39). Patients with evidence of major cardiovascular DESCT findings had higher rates of all-cause death at 90 days (42% vs. 19%, p = 0.037). CONCLUSIONS: In this study, hyperacute cardiac imaging of AIS with DESCT identified a high prevalence of incidental cardiac disease predominantly involving LIE of ischemic etiology and mostly not related to the stroke etiology.

Emerging role of spectral computed tomography in neurocardiology.

The complex and reciprocal relationship between the brain and the heart has gained increasing attention under the concept of neurocardiology. Myocardial injury is common in cerebrovascular disease, and cardiovascular complications are the second leading cause of death after stroke. Cardiac computed tomography (CT) is a fast and reliable non-invasive tool for the assessment of cardioembolic sources. Compared to single energy CT, spectral/dual energy cardiac CT improves tissue characterization and also leads to significant reductions in contrast volume. In this review article, we portray the potential clinical applications of spectral CT in neurocardiology, focusing in the enhanced diagnosis of cardioembolic sources and cardiovascular risk assessment of patients with stroke, including improved detection of thrombus, identification of subtle myocardial disease, and pulmonary complications within the same session.

Early Triage of Cardioembolic Sources Using Chest Spectral Computed Tomography in Acute Ischemic Stroke.

OBJECTIVES: The present study investigated the potential usefulness of delayed-phase, low-dose, non-gated, chest spectral CT scans (DSCT) for the early triage of cardioembolic (CE) sources in patients admitted with acute ischemic stroke (AIS), and for the simultaneous detection of myocardial disease and thrombotic complications. MATERIAL AND METHODS: Since July 2020 and promoted by the COVID-19 pandemic, we implemented the use of DSCT after cerebrovascular CT angiography (CTA) among patients with AIS using a dual-layer spectral CT. We explored the presence of CE sources, as well as late myocardium iodine enhancement (LIE) and pulmonary thromboembolism. Among patients further undergoing transesophageal echocardiogram (TEE) or cardiac CTA, we explored the diagnostic performance. RESULTS: Fifty consecutive patients with AIS who underwent DSCT after cerebrovascular CTA comprised the patient population. The confidence degree for excluding cardiac thrombi was significantly higher than for LIE (4.4±0.8 vs. 3.4±1.3, p<0.0001). DSCT identified a CE source in 4 (8%) and LIE in 24 (48%) patients. The iodine ratio of CE sources was significantly lower compared to the left atrial appendage of patients with no CE sources (0.25±0.1 mg/mL vs. 0.91±0.2 mg/mL, p<0.0001). TEE/cardiac CT, performed in 20 (40%) patients, identified a CE source in 5 (25%) cases, whereas DSCT identified 4 (20%), leading to a sensitivity and specificity of 80% (95% CI 28-99%) and 100% (95% CI 78-100%) respectively (kappa 0.86). CONCLUSIONS: In this pilot study, we identified DSCT as a potential unsophisticated approach for the early triage of CE sources among patients with AIS undergoing CTA upon admission.

Regional differences of fat depot attenuation using non-contrast, contrast-enhanced, and delayed-enhanced cardiac CT.

BACKGROUND: Regional fat density assessed by computed tomography (CT) has been suggested as a marker of perivascular adipose tissue inflammation. Dual energy CT (DECT) allows improved tissue characterization compared to conventional CT. PURPOSE: To explore whether DECT might aid regional fat density discrimination. MATERIAL AND METHODS: We included patients who had completed a non-enhanced cardiac CT scan, CT coronary angiography (CTCA), and a delayed enhancement CT. Attenuation levels (Hounsfield units [HU]) were assessed at the epicardial, paracardial, visceral, and subcutaneous fat. The number of coronary segments with disease (SIS) was calculated. RESULTS: A total of 36 patients were included in the analysis. Twenty-six (72%) patients had evidence of obstructive disease at CCTA and 25 (69%) patients had evidence of previous myocardial infarction. At non-contrast CT, we did not identify significant attenuation differences between epicardial, paracardial, subcutaneous, and visceral fat depots (-110.8 ± 9 HU, vs. -113.7 ± 9 HU, vs. -114.7 ± 8 HU, vs. -113.8 ± 11 HU, P = 0.36). Significant attenuation differences were detected between fat depots at mid and low energy levels, both at CTCA and delayed-enhancement scans ( P < 0.05 for all). Epicardial fat showed the least negative attenuation, irrespective of the acquisition mode; epicardial fat evaluated at 40 keV was related to the SIS (r = 0.37, P = 0.03). CONCLUSIONS: In this study, regional fat depots amenable to examination during thoracic CT scans have distinctive regional attenuation values. Furthermore, such differences were better displayed using contrast-enhanced monochromatic imaging at low energy levels.

Exaggerated Interventricular Dependence Among Patients With Pectus Excavatum: Combined Assessment With Cardiac MRI and Chest CT.

OBJECTIVE: We sought to explore whether patients with pectus excavatum have exaggerated interventricular dependence and to evaluate the impact of the malformation severity (assessed on CT) on both anatomic and functional cardiac parameters (assessed on cardiac MRI). SUBJECTS AND METHODS: The current study involved consecutive patients with a diagnosis of pectus excavatum who were referred to undergo cardiac MRI and chest CT to establish surgical candidacy or to define treatment strategies. RESULTS: Sixty-two patients with pectus excavatum underwent cardiac MRI and chest CT. Fifty (81%) patients were male, and the median age was 17.5 years (range, 14.0-23.0 years). Forty-seven (76%) patients had evidence of right ventricular compression. The left ventricle showed a significantly decreased end-diastolic volume (inspiration vs expiration: 70.4 ± 11.6 vs 76.1 ± 13.7 mL/m2, respectively; p = 0.01) and a significantly higher eccentricity index (1.52 ± 0.2 vs 1.20 ± 0.1, p < 0.0001) during inspiration than during expiration. The median respiratory-related septal excursion was 8.1% (interquartile range, 5.1-11.7%). Patients with pericardial effusion showed a significantly higher pectus excavatum severity index than patients without pericardial effusion (6.3 ± 3.4 vs 4.4 ± 1.3, respectively; p = 0.003). Patients with a relative septal excursion equal to or larger than 11.8% showed a significantly higher pectus excavatum severity index than patients with a relative septal excursion of less than 11.8% (6.3 ± 2.6 vs 4.7 ± 2.4, respectively; p = 0.05). CONCLUSION: In this study, patients with pectus excavatum showed significant alterations of cardiac morphology and function that were related to the deformation severity and that manifest as an exaggerated interventricular dependence.

Detection of Myocardial Infarction Using Delayed Enhancement Dual-Energy CT in Stable Patients.

OBJECTIVE: The objective of our study was to explore whether delayed enhancement dual-energy CT (DECT) allows the detection of myocardial infarcts in stable patients. SUBJECTS AND METHODS: Patients with known or suspected coronary artery disease clinically referred for myocardial perfusion imaging using SPECT were prospectively included. All patients (n = 34) also underwent stress, rest, and delayed enhancement DECT on a DECT scanner. At SPECT, segments with myocardial infarction (MI) were defined as those with a summed rest score of ≥ 2 in two or more consecutive segments, and a diagnosis of MI was supported by wall motion abnormalities, clinical history, and ECG findings. RESULTS: Segments with MI were identified in 13 (38%), 15 (44%), and 14 (41%) patients using SPECT, perfusion CT, and delayed enhancement DECT, respectively. When combined SPECT and perfusion CT results were used as the reference standard, delayed enhancement DECT had a sensitivity, specificity, positive predictive value, and negative predictive value for the detection of MI of 91.7% (95% CI, 62-98%), 86.4% (95% CI, 65-97%), 78.6% (95% CI, 49-95%), and 95.0% (95% CI, 75-100%). At delayed enhancement DECT (40 keV), a signal attenuation higher than 161 HU had a sensitivity of 72% and a specificity of 79% for the detection of MI on a per-segment basis. The median signal attenuation of myocardial infarcts at 40 keV was 3.0 SDs (interquartile range, 1.3-4.0 SDs) above that of normal myocardium. CONCLUSION: In this study, delayed enhancement DECT allowed the detection of myocardial infarcts in stable patients.

Improved Discrimination of Myocardial Perfusion Defects at Low Energy Levels Using Virtual Monochromatic Imaging.

OBJECTIVES: The aim of this study was to explore the diagnostic performance of dual-energy computed tomography perfusion (DE-CTP) at different energy levels. METHODS: Patients with known or suspected coronary artery disease underwent stress and rest DE-CTP and single-photon emission computed tomography. Images were evaluated using monochromatic data, and perfusion defects were initially identified in a qualitative manner and subsequently confirmed using attenuation levels. RESULTS: Thirty-six patients were included. Sensitivity, specificity, positive predictive value, and negative predictive value of DE-CTP for the identification of perfusion defects were 84.1%, 94.2%, 77.3%, and 96.2%, respectively. Perfusion defects showed significantly lower attenuation than normal segments, with the largest differences among low energy levels (sensitivity of 96% and specificity of 98% using a cutoff value ≤ 153 Hounsfield units at 40 keV), progressively declining at the higher levels (P < 0.001). CONCLUSIONS: Dual-energy CTP at the lowest energy levels allowed improved discrimination of perfusion defects compared with higher energy levels.

Noninvasive Cardiac Imaging in Patients with Known and Suspected Coronary Artery Disease: What is in it for the Interventional Cardiologist?

The long-standing coronary artery disease (CAD) paradigm simplified by the discrimination between patients with or without CAD warrants to be revisited by the insightful information provided by noninvasive cardiac imaging, leading to a comprehensive physiopathological assessment rather than a mainly anatomical approach. This review will address (1) the role of non-invasive cardiac imaging for the appropriate selection of stable patients referred to invasive coronary angiography (ICA), and the evolving concept and prognostic implications of myocardial ischemia; (2) the usefulness of computed tomography coronary angiography for the guidance of percutaneous coronary interventions; and (3) the role and potential clinical impact of novel anatomical and functional non-invasive prognostic markers.

Noncontrast Myocardial Characterization in Acute Myocardial Infarction Using Electron Density Imaging.

PURPOSE: Spectral computed tomography (CT) enables improved tissue characterization, although virtually all research has focused on contrast-enhanced examinations. We hypothesized that changes in myocardial tissue related to acute myocardial infarction (AMI) might potentially be identified without the need for contrast administration using electron density (ED) imaging. PATIENTS AND METHODS: This retrospective observational study involved a small series (n = 15) of patients admitted to our institution with a first AMI without signs of hemodynamic instability and identification of a culprit vessel with invasive coronary angiography during the same admission, who also underwent a noncontrast, low-dose chest CT using a dual-layer spectral CT scanner. Images were assessed in search of dark areas with low density on ED imaging, and the mean percentage ED relative to water (%EDW) was calculated. RESULTS: Using a qualitative approach, ED assessment enabled the identification of 11/15 (73%) affected coronary territories, with a sensitivity of 73% (95% CI: 45; 92%) and a specificity of 87% (95% CI: 69; 96%). AMI segments showed significantly lower ED values than the remote myocardium (103.8 ± 0.8 vs 104.3 ± 0.6 %EDW, P < 0.0001), and a threshold below 103.9 %EDW had a sensitivity of 66% and specificity of 79% for the identification of AMI. In a control group of patients without a history of cardiovascular disease, none had areas with focal reduction of ED following the shape of the myocardial wall. CONCLUSIONS: In our preliminary series, ED imaging showed the potential to enable the identification of myocardial tissue changes related to AMI without iodinated contrast requirement.

Thrombus discrimination with electron density: potential implications for non-contrast computed tomography imaging.

The potential clinical usefulness of electron density (ED) imaging, that can be directly estimated using dual-layer spectral computed tomography (CT), has been poorly investigated. We explored whether ED imaging might improve thrombus identification compared to conventional imaging in vitro. We evaluated mechanical thrombectomy material obtained from patients with acute ischemic stroke (AIS) treated in a tertiary level stroke center and immediately fixed in 10% neutral buffered formalin and stored in polystyrene test tubes. The test tubes were immersed in a bucket of water for evaluation by spectral CT, along with scattered control tubes. All images were obtained using a dual-layer detector CT scanner. Each tube was assessed using multiparametric side-by-side view of conventional CT (120 kVp), low monoenergetic imaging (40 keV), and ED images. Fifty-eight polystyrene tubes were analyzed, comprising 52 tubes with thrombectomy material of at least 1 mm2 size obtained from 52 AIS patients, and six control tubes filled with formalin. ED imaging identified accurately the presence of material in all tubes, whereas 2 (3%) of the tubes containing thrombus were not identified by conventional CT, leading to a very good agreement between observers for the presence of material using conventional CT and ED imaging (kappa =0.84, P<0.001). Using ED imaging, thrombus material showed a mean density of 108.8±2.9 percent ED relative to water (%EDW), water had a mean density of 100.0±0.3 %EDW, and formalin a mean density of 103.5±1.2 %EDW. Compared to conventional imaging and 40 keV monoenergetic, ED imaging had a significantly higher signal-to-noise ratio (conventional 10.4±7.0, vs. 40 keV 11.5±8.4, vs. ED 490.0±304.5, P<0.001) and contrast-to-noise ratio (CNR) (conventional 4.3±4.3, vs. 40 keV 5.7±11.2, vs. ED 37.8±29.1, P<0.001). In this in-vitro study, we demonstrated improved visualization of thrombus with ED imaging compared to conventional imaging and low monoenergetic imaging, with a significant increase in CNR.

Unsophisticated assessment of the cardiopulmonary function in patients with pectus excavatum using the six minute walk test.

BACKGROUND: We explored whether the maximum predicted walking distance, assessed with six-minute walk test (6MWT) and reflecting submaximal functional exercise capacity, is decreased among patients with pectus excavatum (PEX). METHODS: This study comprised a retrospective analysis of patients with PEX who underwent a 6MWT for the assessment of functional capacity. The maximum distance walked was recorded and compared to reference values established for different populations, including a young and healthy South American population. RESULTS: We included 43 patients with PEX who underwent 6MWT. The mean age was 17.8 ± 6.7 years. The mean maximum distance walked was significantly lower than the predicted distance (600.8 ± 67.6 metres vs. 729.8 ± 67.5 metres, p < 0.0001). Using the Enright reference equation including an older reference population, the mean negative difference was higher (PEX patients walked 190.4 ± 78.4 metres less than predicted, p < 0.0001). We also applied the Li et al. reference equation accounting for sex among other variables, detecting a decreased walked distance compared to the gender-adjusted predicted distance (PEX patients walked a mean 222.4 ± 87.4 metres less than predicted, p < 0.0001). Using the Ulrich et al. equation, PEX patients walked a mean 114.2 ± 85.1 metres less than predicted (p < 0.0001). Although of uncertain clinical relevance, there was a significant decrease in the mean oxygen saturation after exercise (baseline 97.4 ± 1.2%, vs. final 96.4 ± 2.1%, p = 0.006). CONCLUSIONS: In this study, we identified a significant reduction in the maximum walked distance among patients with PEX compared to the predicted distance, thus potentially emerging as an unsophisticated means to evaluate and quantify functional exercise capacity.

Randomized comparison of cost-saving and effectiveness of oral rapamycin plus bare-metal stents with drug-eluting stents: three-year outcome from the randomized oral rapamycin in Argentina (ORAR) III trial.

OBJECTIVES: The Oral Rapamycin in ARgentina (ORAR) III trial is a randomized study comparing a strategy of oral rapamycin (OR) plus bare-metal stent (BMS) versus a strategy of drug-eluting stents (DES) in patients with de novo coronary lesions. The purpose of this study was to assess the 3 years cost-effectiveness outcome of each strategy. BACKGROUND: OR after BMS has been associated with reduction of target vessel revascularization (TVR) although its value in long-term efficacy in comparison with DES is unknown. METHODS: In three hospitals in Buenos Aires, Argentina, 200 patients were randomized to OR plus BMS (n = 100) or DES (n = 100). Primary objectives were costs and effectiveness. Cost analysis included in-hospital and follow-up costs. Safety was defined as the composite of death, myocardial infarction (MI), and stroke. Efficacy was defined as TVR. RESULTS: Baseline characteristics between groups were similar. The 3-year follow-up rate was 99%. Cardiac mortality was 2% and 5% in OR group and DES group, respectively (P = 0.44). The composite of death, MI and stroke rate was 11% in OR group and 20% in DES group (P = 0.078). TVR rate was 14.5% in OR group and 17.6% in DES group (P = 0.50), respectively. Three year cumulative costs were significantly lower in the OR arm as compared to the DES arm (P = 0.0001) and DES strategy did not result cost-effective according to the non-inferiority test. CONCLUSIONS: At 3 years follow-up, there were no differences in effectiveness between the two strategies, and DES strategy was not more cost-effective as compared to OR plus BMS.

Epicardial and periaortic fat characteristics in ischemic stroke: Relationship with stroke etiology and calcification burden.

PURPOSE: We explored epicardial (EAT) and periaortic (PAT) adipose tissue characteristics in patients with acute ischemic stroke (AIS), and the relationship with stroke etiology, calcification burden, and inflammation. METHOD: We included a retrospective cohort of consecutive patients admitted with AIS between 2015 and 2020 who underwent a chest computed tomography. We calculated volumes and attenuation of EAT and PAT, and coronary artery (CAC), and thoracic aortic (TAC) calcification. Admission's neutrophil/lymphocyte ratio (NLR) was recorded. Stroke severity was assessed using the National Institute of Health Stroke Scale (NIHSS), and patients were discriminated between cardioembolic (CE), non-CE, and embolic strokes of uncertain source (ESUS). RESULTS: A total of 182 patients were included. EAT (non-CE 127.4 ± 47.1 cm3; CE 133.3 ± 56.7 cm3; ESUS 121.6 ± 63.5 cm3, p > 0.05) and PAT (non-CE 37.4 ± 18.6 cm3; CE 40.4 ± 17.2 cm3; ESUS 34.5 ± 14.1 cm3, p > 0.05) volumes were similar between stroke etiologies. Patients with CE stroke had higher PAT attenuation (PAT = non-CE -84.4 ± 7.0 HU; CE -78.1 ± 9.9 HU; ESUS -82.3 ± 9.3 HU, p < 0.001). Using multiple linear regression, albeit weak, we found a significant relationship between NLR and PAT attenuation [Beta 0.24; (95% CI 0.04-0.51), p < 0.05). Despite similar volume, PAT attenuation was higher (p < 0.01) among demised patients. CONCLUSION: In this study, we identified higher periaortic fat attenuation, despite similar fat volume, in patients with CE stroke.

Usefulness of strain cardiac magnetic resonance for the exposure of mild left ventricular systolic abnormalities in pectus excavatum.

BACKGROUND: Systolic dysfunction in pectus excavatum (PEX) is usually very subtle and mainly focused on the right ventricle (RV), leading to normal or unremarkable cardiac imaging findings unless involving exercise stress. OBJECTIVES: We evaluated systolic function in PEX using longitudinal strain cardiac magnetic resonance (CMR), a validated parameter for the assessment of the systolic deformation of subendocardial fibers. METHODS: This prospective registry comprised consecutive patients with PEX who were referred to CMR to define treatment strategies or to establish surgical candidacy. We also included a control group of 15 healthy volunteers without chest wall abnormalities. Using dedicated software, we evaluated the endocardial global longitudinal strain (GLS) of both ventricles and the endocardial global circumferential strain (GCS) of the left ventricle (LV). RESULTS: A total of 50 patients with PEX comprised the study population, with a mean age of 19.9 ± 8.0 years. The right ventricular ejection fraction (RVEF) of patients with PEX was significantly lower compared to the control group both at end-expiration (59.5 ± 6.8 vs. 64.7 ± 4.7%, p = 0.008) and end-inspiration (56.7 ± 7.2%, vs. 62.7 ± 4.4, p = 0.004); as well as the pulmonary stroke distance (12.6 ± 2.5, vs. 15.0 ± 2.0 cm, p = 0.001). The LV volumetric analysis revealed no differences between PEX and the control group (p > 0.05 for all) regardless of the respiratory cycle, with a mean expiratory LV ejection fraction (LVEF) of 61.4 ± 6.0%. In contrast, the GLS of the LV was significantly lower in PEX compared to controls (-21.2 ± 3.2 vs. -23.7 ± 3.0%, p = 0.010), whereas GCS was similar either at expiration (-28.5 ± 4.0%, vs. -29.5 ± 2.8, p = 0.38) or inspiration (-29.3 ± 4.1%, vs.-28.9 ± 2.3, p = 0.73). CONCLUSIONS: In this study, we demonstrated that longitudinal strain analysis might enable the detection of very subtle left ventricular systolic function abnormalities in patients with PEX, that are commonly overlooked using the conventional assessment. LEVEL OF EVIDENCE: II.

Interplay between climate, pollution and COVID-19 on ST-elevation myocardial infarction in a large metropolitan region.

BACKGROUND: Collective risk factors such as climate and pollution impact on the risk of acute cardiovascular events, including ST-elevation myocardial infarction (STEMI). There is limited data however on the precise temporal and independent association between these factors and STEMI, and the potentially interacting role of government policies against Coronavirus disease 2019 (COVID-19), especially for Latin America. METHODS: We retrospectively collected aggregate data on daily STEMI admissions at 10 tertiary care centers in the Buenos Aires metropolitan area, Argentina, from January 1, 2017 to November 30, 2020. Daily measurements for temperature, humidity, atmospheric pressure, wind direction, wind speed, and rainfall, as well as carbon monoxide (CO), nitrogen dioxide, and particulate matter <10 µm (PM10), were retrieved. Exploratory analyses focused on key COVID-19-related periods (e.g. first case, first lockdown), and Stringency Index quantifying the intensity of government policy response against COVID-19. RESULTS: A total of 1498 STEMI occurred over 1430 days, for an average of 0.12 STEMI per center (decreasing from 0.130 in 2018 to 0.102 in 2020, P=0.016). Time series analysis showed that lower temperature and higher concentration of CO and PM10 were all significantly associated with an increased rate of STEMI (all P<0.05), whereas COVID-19 outbreak, lockdown, and stringency of government policies were all inversely associated with STEMI (all P<0.05). Notably, environmental features impacted as early as 28 days before the event (all P<0.05), even if same or prior day associations proved stronger (all P<0.05). Multivariable analysis suggested that maximum temperature (P=0.001) and PM10 (P=0.033) were the strongest predictor of STEMI, even after accounting for COVID-19-related countermeasures (P=0.043). CONCLUSIONS: Lower temperature and higher concentrations of CO and PM10 are associated with significant increases in the rate of STEMI in a large Latin American metropolitan area. The reduction in STEMI cases seen during the COVID-19 pandemic is at least in part mediated by improvements in pollution, especially reductions in PM10.

Cardiovascular thrombotic complications in acute ischemic stroke assessed by chest spectral computed tomography during COVID-19.

During the pandemic context, diagnostic algorithms had to be adapted considering the decimated medical personnel, local technical resources, and the likelihood of contamination. Given the higher probability of thrombotic complications related to COVID-19 and the availability of a dual-layer spectral computed tomography (CT) scanner, we have recently adopted the use of low-dose, non-gated, chest CT scans performed five minutes after contrast administration among patients admitted with acute ischemic stroke (AIS) undergoing cerebrovascular CT angiography. Dual-layer spectral CT comprises a single X-ray source and two-layer detector with different photon-absorption capabilities. In addition to conventional images, the two distinct energy datasets obtained enable multiparametric spectral analysis without need to change the original scanning protocol. The two spectral features that emerge as most useful for patients with AIS are virtual monoenergetic imaging and iodine-based results. Aside from the evaluation of lung parenchyma, this novel strategy enables ruling out cardioembolic sources and simultaneously providing evidence of pulmonary and myocardial injury in a single session and immediately after CT cerebrovascular angiography. Furthermore, it involves a non-invasive, seemingly accurate, unsophisticated, safer (very low radiation dose and no contrast administration), and cheaper tool for ruling out cardioembolic sources compared to transesophageal echocardiogram and cardiac CT. Accordingly, we sought to standardize the technical aspects and overview the usefulness of delayed-phase, low-dose chest spectral CT in patients admitted with AIS.

Anatomic or functional testing in stable patients with suspected CAD: contemporary role of cardiac CT in the ISCHEMIA trial era.

One of the foundations of the management of patients with suspected coronary artery disease (CAD) is to avoid unnecessary invasive coronary angiography (ICA) referrals. However, the diagnostic yield of ICA following abnormal conventional stress testing is low. The ability of ischemia testing to predict subsequent myocardial infarction and death is currently being challenged, and more than half of cardiac events among stable patients with suspected CAD occur in those with normal functional tests. The optimal management of patients with stable CAD remains controversial and ischemia-driven interventions, though improving anginal symptoms, have failed to reduce the risk of hard cardiovascular events. In this context, there is an ongoing debate whether the initial diagnostic test among patients with stable suspected CAD should be a functional test or coronary computed tomography angiography. Aside from considering the specific characteristics of individual patients and local availability and conditions, the choice of the initial test relates to whether the objective concerns its role as gatekeeper for ICA, prognosis, or treatment decision-making. Therefore, the aim of this review is to provide a contemporary overview of these issues and discuss the emerging role of CCTA as the upfront imaging tool for most patients with suspected CAD.