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Transesophageal echocardiography in patients with cryptogenic cerebral ischemia
Fabian Knebel1, Florian Masuhr, Wolfram von Hausen
1Charité Universitatsmedizin Berlin, Campus Mitte, Medizinische Klinik und Poliklinik mit Schwerpunkt Kardiologie und Angiologie, Berlin, Germany. fabian.knebel@charite.de
Insights
Transesophageal echocardiography (TEE) reveals cardiogenic factors in over half of cryptogenic stroke patients. Younger patients show more patent foramen ovale (PFO), while older patients exhibit atherosclerotic findings, indicating TEE is crucial for all ages.
Area of Science:
- Cardiology
- Neurology
- Diagnostic Imaging
Background:
- Approximately one-third of cerebral ischemia cases are cryptogenic (unknown cause).
- Cardiogenic etiologies are often identified in patients initially diagnosed with cryptogenic stroke.
- Echocardiographic assessment is vital for uncovering potential cardiac causes.
Purpose of the Study:
- To determine the prevalence of abnormal echocardiographic findings in patients with cryptogenic cerebral ischemia.
- To investigate the diagnostic yield of transesophageal echocardiography (TEE) in this patient population.
- To identify specific echocardiographic findings associated with different age groups and stroke types.
Main Methods:
- Inclusion of 702 patients with cryptogenic ischemic stroke (IS) or transient ischemic attack (TIA).
- Comprehensive initial work-up including neurological examination, ECG, Holter-ECG, and Doppler ultrasound.
- Multiplane transesophageal echocardiography (TEE) performed on all participants, including contrast and Valsalva maneuver.
Main Results:
- TEE revealed relevant findings in 52.6% of all patients.
- Common findings included patent foramen ovale (PFO, 21.7%), valvular disease (15.8%), aortic plaques, and atrial septal defects.
- Older patients (>55 years) and IS patients had more findings; younger patients showed higher prevalence of PFO and atrial septal defects (ASD).
Conclusions:
- Transesophageal echocardiography (TEE) identifies cardiogenic factors in about half of cryptogenic stroke patients.
- Age-specific differences in findings: PFO/ASD in younger patients, atherosclerotic findings in older patients.
- TEE is recommended for all cryptogenic stroke patients due to potential therapeutic implications.
Background:
In about one third of all patients with cerebral ischemia, no definite cause can be identified (cryptogenic stroke). In many patients with initially suspected cryptogenic stroke, however, a cardiogenic etiology can eventually be determined. Hence, the aim of this study was to describe the prevalence of abnormal echocardiographic findings in a large number of these patients.
Method:
Patients with cryptogenic cerebral ischemia (ischemic stroke, IS, and transient ischemic attack, TIA) were included. The initial work-up included a neurological examination, EEG, cCT, cMRT, 12-lead ECG, Holter-ECG, Doppler ultrasound of the extracranial arteries, and transthoracic echocardiography. A multiplane transeophageal echocardiography (TEE, including i.v. contrast medium application [Echovist], Valsalva maneuver) was performed in all patients
Results:
702 consecutive patients (380 male, 383 IS, 319 TIA, age 18-90 years) were included. In 52.6% of all patients, TEE examination revealed relevant findings. Overall, the most common findings in all patients were: patent foramen ovale (21.7%), previously undiagnosed valvular disease (15.8%), aortic plaques, aortic valve sclerosis, atrial septal aneurysms, regional myocardial dyskinesia, dilated left atrium and atrial septal defects. Older patients (> 55 years, n = 291) and patients with IS had more relevant echocardiographic findings than younger patients or patients with TIA, respectively (p = 0.002, p = 0.003). The prevalence rates of PFO or ASD were higher in younger patients (PFO: 26.8% vs. 18.0%, p = 0.005, ASD: 9.6% vs. 4.9%, p = 0.014).
Conclusion:
A TEE examination in cryptogenic stroke reveals contributing cardiogenic factors in about half of all patients. Younger patients had a higher prevalence of PFO, whereas older patients had more frequently atherosclerotic findings. Therefore, TEE examinations seem indicated in all patients with cryptogenic stroke - irrespective of age - because of specific therapeutic consequences.
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