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Published on: February 8, 2022
Routine transesophageal echocardiography for the evaluation of cerebral emboli in elderly patients
Sergey Vitebskiy1, Keith Fox, Brian D Hoit
1University Hospitals of Cleveland and Case Western Reserve University, Cleveland, OH 44106-5038, USA.
Insights
Transesophageal echocardiography (TEE) reveals more abnormalities in elderly patients with stroke, but these are often sessile aortic atheroma and atrial septal aneurysm, not typically linked to cardioembolic events. Routine TEE may not be warranted in this population until specific therapies are proven beneficial.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Cardioembolic stroke accounts for approximately 20% of all cerebral infarctions.
- Transesophageal echocardiography (TEE) is the primary diagnostic tool for evaluating cardiac sources of embolism.
- The diagnostic utility of TEE in elderly patients with cerebrovascular accidents remains poorly defined.
Purpose of the Study:
- To evaluate the diagnostic yield of Transesophageal Echocardiography (TEE) in elderly patients (over 65) with suspected embolic stroke or transient ischemic attack (TIA).
- To compare the incidence of thromboembolic disease abnormalities detected by TEE in elderly patients with stroke/TIA versus a matched control group.
Main Methods:
- A retrospective comparison of 491 elderly patients (≥65 years) who underwent TEE for suspected embolic stroke/TIA with 252 age-, sex-, and time-matched controls.
- Review of TEE studies for abnormalities associated with thromboembolic disease, including left atrial thrombi, aortic atheromata, atrial septal aneurysm, spontaneous echocontrast, and patent foramen ovale.
Main Results:
- Elderly patients with suspected embolic stroke/TIA showed a higher incidence of certain TEE abnormalities compared to controls.
- These abnormalities were primarily sessile aortic atheroma and atrial septal aneurysm.
- No significant differences were found in the incidence of left atrial thrombi, complex or mobile aortic atheromata, spontaneous echocontrast, or patent foramen ovale between the groups.
Conclusions:
- While TEE detects more abnormalities in elderly patients with cerebral infarction, these findings are often related to sessile aortic atheroma and atrial septal aneurysm.
- The clinical significance and benefit of specific therapies for these identified abnormalities in preventing stroke are not yet established.
- Routine TEE in elderly individuals with suspected embolic neurological events is currently considered unwarranted pending further evidence.
Background:
Approximately 20% of cerebral infarctions are cardioembolic in nature. Transesophageal echocardiography (TEE) is widely regarded as the initial study of choice for evaluating cardiac source of embolism. Although the majority of cerebrovascular accidents occur in elderly patients, the value of TEE in this population is poorly defined.
Methods:
We compared 491 patients older than 65 years with suspected embolic stroke or transient ischemic attack (TIA) who had undergone TEE evaluation between April 2000 and February 2004 to an age-, sex-, and time-matched control group that consisted of 252 patients. Studies were reviewed for abnormalities associated with thromboembolic disease.
Results:
The overall incidence of stroke risk factors was significantly higher in the study than in the control group. However, the four patients with left atrial thrombi had a history of atrial fibrillation. Although ascending and aortic arch sessile atheromata were observed more frequently in the study than control group, there were no significant differences in the incidence of either complex or mobile aortic atheromata. The incidence of atrial septal aneurysm was higher in the stroke/TIA group, but not in association with patent foramen ovale. Finally, there were also no differences in the incidence of spontaneous echocontrast, and/or patent foramen ovale between study and control groups.
Conclusions:
We conclude: (1) There is a higher incidence of abnormalities implicated as sources of thromboembolic disease on TEE in elderly patients with cerebral infarctions, but (2) this incidence is driven by the presence of sessile aortic atheroma and atrial septal aneurysm. Until the benefits of specific therapies for these conditions are known, routine TEE in elderly patients with suspected embolic neurological events appears to be unwarranted.
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