WSC 2025 | Cardiac imaging in stroke: uncovering causes and guiding patient management

Cardiac imaging is a key component in the stroke etiologic investigation. And currently, first-line exam is echocardiography. However, echocardiography has some limitations. It makes sense also that as time went by, that new imaging modality emerged. And that’s the case for CMR. So CMR is an imaging exam that’s complementary to the other ones. And it’s especially good to see left ventricular thrombi and also to investigate cardiomyopathies. And if the patient has already undergone a completely standard examination, etiological examination, this is normal, and you think that the patient has an embolic pattern, you should consider doing CMR because it can help you to establish the cardiomyopathy cause. And there’s also some ongoing possible mechanisms that have been evaluated like, for example, arrhythmogenic cardiomyopathy, silent myocardial ischemia, that CMR is especially good to detect. If you find thrombus, the patient has to be anti-coagulated because there are some studies that have already shown that if you find thrombus, only on MRI but not in the echocardiogram, the risk is the same of embolizing. So those patients should be treated with anticoagulation. Regarding cardiomyopathies, the question is a little bit more tricky because we don’t have randomized clinical trials that have weighed treatment in patients with non-compaction cardiomyopathy, hypertrophic cardiomyopathy, or restrictive cardiomyopathy. But most cardiologists agree that if the patient’s already had a stroke, he should be anticoagulated.

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