Cardiac imaging in ischemic stroke or transient ischemic attack of undetermined cause: Systematic review &
Gerlinde van der Maten1, Saskia Dijkstra2, Matthijs F L Meijs3
1Department of Neurology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, the Netherlands; Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente, Drienerlolaan 5, 7522 NB Enschede, the Netherlands.
Insights
Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) rarely identify major cardioembolic sources in cryptogenic stroke or transient ischemic attack (TIA) patients. Further research is needed to guide evidence-based imaging decisions.
Area of Science:
- Cardiology
- Neurology
- Diagnostic Imaging
Background:
- Ischemic stroke and transient ischemic attack (TIA) of undetermined cause often prompt cardiac imaging to find cardioembolic sources.
- The optimal imaging strategy remains debated, with evolving therapeutic implications.
Purpose of the Study:
- To evaluate the diagnostic yield of transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and cardiac computed tomography (CT) for detecting cardioembolic sources in patients with cryptogenic stroke or TIA.
Main Methods:
- A systematic review and meta-analysis adhering to PRISMA guidelines.
- Inclusion of studies assessing consecutive patients with cryptogenic stroke or TIA.
- Calculation of pooled prevalence for each type of cardioembolic source detected by TTE, TEE, or cardiac CT.
Main Results:
- Only six studies (1022 patients) met inclusion criteria; no studies assessed cardiac CT.
- TTE detected 43 cardioembolic sources (1.3% major) in 316 patients.
- TEE detected 248 cardioembolic sources (5.9% major) in 937 patients, with left atrial appendage thrombus being the most prevalent major source.
Conclusions:
- TTE and TEE infrequently detect major cardioembolic sources necessitating a change in therapy for cryptogenic stroke or TIA.
- Study findings require cautious interpretation due to the limited number of included studies.
- A large prospective clinical trial is recommended to inform evidence-based decision-making for cardiac imaging in these patients.
Background:
Patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause often undergo cardiac imaging in search of a cardioembolic source. As the choice of the most appropriate imaging approach is controversial and therapeutic implications have changed over time, we aimed to identify in patients with "cryptogenic stroke or TIA" the yield of transthoracic or transesophageal echocardiography (TTE or TEE) and cardiac computed tomography (CT).
Methods And Results:
We performed a systematic review and meta-analysis according to the PRISMA guidelines. Included were studies that assessed consecutive patients with ischemic stroke or TIA of undetermined cause to evaluate the yield of TTE, TEE, or cardiac CT for detecting cardioembolic sources. For each type of cardioembolic source the pooled prevalence was calculated. Only six out of 1458 studies fulfilled the inclusion criteria (1022 patients). One study reported the yield of TTE, four of TEE, and one of both TTE and TEE; no study assessed cardiac CT. Mean patient age ranged from 44.3-71.2 years, 49.2-59.7% were male. TTE detected 43 cardioembolic sources in 316 patients (4 (1.3%) major, 39 (12.3%) minor), and TEE 248 in 937 patients (55 (5.9%) major, 193 (20.6%) minor). The most prevalent major cardioembolic source was left atrial appendage thrombus, yet results were heterogeneous among studies.
Conclusions:
TTE and TEE infrequently detect major cardioembolic sources that require a change of therapy. Findings should be interpreted with caution due to the limited number of studies. A large-sized prospective clinical trial is warranted to support evidence-based decision-making.
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