Problems in the recognition of aortoembolic stroke

Area of Science:

• Cardiology
• Neurology
• Vascular Medicine

Background:

• Aortoembolism is increasingly recognized as a significant cause of stroke.
• Transesophageal echocardiography (TEE) can visualize the aortic arch, a potential source of emboli.
• Diagnosis of aortoembolism-related stroke remains uncommon despite TEE availability.

Purpose of the Study:

• To investigate the reasons for the underdiagnosis of aortoembolism as a cause of stroke.
• To evaluate the discrepancy between official TEE reports and expert review of aortic arch visualization.

Main Methods:

• Retrospective review of 16 patients with ischemic stroke or TIA who underwent TEE.
• Comparison of official TEE reports with independent videotape review focusing on aortic arch pathology.
• Determination of the most likely cause of cerebral ischemia for each patient.

Main Results:

• Aortic arch atherosclerosis was present in 6 of 13 adequately visualized arches.
• Official TEE reports failed to mention aortic arch disease in 4 of these 6 patients.
• Cerebral ischemia causes were identified in most patients with normal aortic arches, but remained unknown in some with poor visualization or aortic disease.

Conclusions:

• Aortic arch disease is a frequent finding in patients with ischemic stroke and TIA.
• Underdiagnosis stems from poor TEE visualization, lack of reporting, or failure to consider the aorta as an embolic source.
• Improved TEE interpretation and reporting are crucial for identifying aortoembolism as a stroke etiology.