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Treatment-Relevant Findings in Transesophageal Echocardiography After Stroke: A Prospective Multicenter Cohort Study
Götz Thomalla1, Mira Upneja1, Stephan Camen2
1Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.).
Insights
Transesophageal echocardiography (TEE) offers greater diagnostic value than transthoracic echocardiography (TTE) for identifying stroke causes. TEE is particularly beneficial for younger stroke patients, revealing crucial findings in one in seven individuals under 60.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Cardiac ultrasound is crucial for diagnosing cardioembolic sources in acute ischemic stroke.
- The added value of transesophageal echocardiography (TEE) over transthoracic echocardiography (TTE) for stroke workup remains debated.
Purpose of the Study:
- To evaluate the incremental diagnostic yield of TEE when added to TTE in patients with acute ischemic stroke of undetermined origin.
Main Methods:
- A prospective, observational, multicenter cohort study involving patients with acute ischemic stroke or TIA of undetermined cause.
- Patients underwent both TTE and TEE, with treatment-relevant findings defined by expert consensus.
- Primary outcome was the rate of treatment-relevant findings; secondary outcomes included changes in stroke cause assessment.
Main Results:
- TEE identified significantly more treatment-relevant findings than TTE (18.9% vs. 14.1%, P<0.001).
- Adding TEE yielded additional treatment-relevant findings in 6.4% of patients.
- In patients ≤60 years, TEE revealed additional findings in 14.1%.
Conclusions:
- TEE provides a higher rate of treatment-relevant findings compared to TTE in stroke patients with undetermined causes.
- TEE is particularly valuable in younger stroke patients (≤60 years), identifying critical findings in approximately 14%.
Background And Purpose:
Cardiac ultrasound to identify sources of cardioembolism is part of the diagnostic workup of acute ischemic stroke. Recommendations on whether transesophageal echocardiography (TEE) should be performed in addition to transthoracic echocardiography (TTE) are controversial. We aimed to determine the incremental diagnostic yield of TEE in addition to TTE in patients with acute ischemic stroke with undetermined cause.
Methods:
In a prospective, observational, pragmatic multicenter cohort study, patients with acute ischemic stroke or transient ischemic attack with undetermined cause before cardiac ultrasound were studied by TTE and TEE. The primary outcome was the rate of treatment-relevant findings in TTE and TEE as defined by a panel of experts based on current evidence. Further outcomes included the rate of changes in the assessment of stroke cause after TEE.
Results:
Between July 1, 2017, and June 30, 2019, we enrolled 494 patients, of whom 492 (99.6%) received TTE and 454 (91.9%) received TEE. Mean age was 64.7 years, and 204 (41.3%) were women. TEE showed a higher rate of treatment-relevant findings than TTE (86 [18.9%] versus 64 [14.1%], P<0.001). TEE in addition to TTE resulted in 29 (6.4%) additional patients with treatment-relevant findings. Among 191 patients ≤60 years additional treatment-relevant findings by TEE were observed in 27 (14.1%) patients. Classification of stroke cause changed after TEE in 52 of 453 patients (11.5%), resulting in a significant difference in the distribution of stroke cause before and after TEE (P<0.001).
Conclusions:
In patients with undetermined cause of stroke, TEE yielded a higher number of treatment-relevant findings than TTE. TEE appears especially useful in younger patients with stroke, with treatment-relevant findings in one out of seven patients ≤60 years.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT03411642.
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