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Transesophageal echocardiography for identifying potential cardiac sources of embolism in patients with stroke
A Palazzuoli1, D Ricci, C Lenzi
1Istitute of Internal Medicine, University of Siena, Policlinico Le Scotte, Italy.
Insights
Transesophageal echocardiography (TEE) is more sensitive than transthoracic echocardiography (TTE) for detecting cardiac sources of stroke. TEE identified potential causes in 86% of patients with unexplained stroke, guiding further investigation.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Cerebral circulation pathologies are a leading cause of mortality and morbidity.
- Cardioembolic stroke incidence ranges from 13% to 34%, higher in younger patients.
- Identifying cardiac embolism sources is crucial for unexplained stroke management.
Purpose of the Study:
- To compare the diagnostic utility of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) in patients with unexplained stroke.
- To identify cardiac sources of embolism in patients with negative vascular imaging.
- To evaluate the sensitivity and specificity of TEE versus TTE.
Main Methods:
- Prospective study of 73 patients with unexplained stroke and negative carotid/vertebral sonography.
- All patients underwent both TTE and TEE.
- Data on identified cardiac anomalies were collected and compared between TEE and TTE.
Main Results:
- TEE identified potential embolic sources in 86% of patients, including spontaneous echocontrast, patent foramen ovale, and complex aortic plaque.
- Definite stroke sources (clots, tumors) were found in 14% of cases.
- TEE demonstrated significantly greater sensitivity and specificity compared to TTE.
Conclusions:
- TEE is superior to TTE in detecting cardiac sources of embolism in unexplained stroke.
- While TTE provides initial useful information, TEE is essential for comprehensive evaluation.
- A strategy of performing TTE before TEE is recommended to guide further investigations.
Abstract:
Pathologies of cerebral circulation are one of the most frequent causes of mortality and morbidity among the populations of Western countries. The incidence of ischemic events presumed to have a cardioembolic origin varies from 13% to 34% in the largest international multi-center studies. However, some authors have reported an incidence of general cardiogenic stroke ranging from 23% to 36% in younger patients. Transesophageal echocardiography (TEE) is a useful investigation for identifying cardiac sources of embolism in patients without vascular alterations involving the carotid and vertebral districts. This study comprised 73 patients with unexplained stroke who were investigated by both transthoracic echocardiography (TTE) and TEE. Vascular echocolor sonography had been performed in all of them with negative results. TEE demonstrated: atrial or ventricular thrombosis in 6 patients (8%), intracavitary neoplasm in 2 (2%), spontaneous echocontrast in 11 (13%), valve strands in 6 (7%), complex aortic plaque in 10 (11%), patency of the foramen ovale in 17 (19%), atrial septal aneurysm in 9 (11%), dystrophy and mitral calcifications in 9 (11%). In the other 18 patients, TEE did not reveal any anomalies. Definite sources of stroke (clots and tumors) were identified in 14% of all the lesions; however, the majority (86%) were potential sources. A comparison of the two echocardiographic techniques demonstrated a greater sensitivity and specificity of TEE. Although TEE was superior to TTE for identifying and evaluating potential embolic sources, we found both methods to be useful and would advise performing TTE before TEE. While TTE is not capable of identifying the majority of anomalies, it does provide useful information to guide subsequent transesophageal investigations.