Clinical Utility of the Transthoracic Echocardiogram for Isolated Lacunar Infarcts: A Single-Center Experience
Jeffrey Z Nie1, Matthew W Weber1, Kiddy Ume2
1Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, IL.
Insights
Transthoracic echocardiograms offer minimal benefit for lacunar stroke patients without cardiac symptoms. Routine screening may lead to unnecessary healthcare spending, suggesting it
Area of Science:
- Neurology
- Cardiology
- Medical Imaging
Background:
- Stroke represents a significant health burden, with lacunar strokes traditionally linked to small vessel disease.
- The role of cardioembolic source screening, including transthoracic echocardiograms, in lacunar stroke patients remains uncertain.
- Evaluating the clinical utility of transthoracic echocardiograms in this specific patient population is crucial for optimizing diagnostic strategies.
Purpose of the Study:
- To assess the clinical utility and diagnostic yield of transthoracic echocardiograms in patients diagnosed with lacunar strokes.
- To determine if transthoracic echocardiograms reveal findings that alter patient management or lead to specific interventions in lacunar stroke cases.
Main Methods:
- Retrospective analysis of ischemic stroke patients diagnosed between January 2013 and December 2017.
- Inclusion criteria focused on patients with a single lacunar infarct confirmed by brain MRI, excluding those with acute cardiac symptoms or ECG abnormalities.
- Transthoracic echocardiogram results were reviewed to evaluate their impact on clinical decision-making.
Main Results:
- Out of 442 ischemic stroke patients, 89 met the criteria for lacunar stroke.
- Transthoracic echocardiograms identified patent foramen ovale in 5.6%, mitral annular calcification in 9.0%, and abnormal wall motion in 4.5% of patients.
- No findings from the echocardiograms prompted anticoagulation, antibiotic, or surgical interventions, and the average cost per inpatient study was $4100.
Conclusions:
- Transthoracic echocardiograms demonstrate minimal therapeutic value in the majority of lacunar stroke patients.
- Consideration should be given to withholding transthoracic echocardiograms in lacunar stroke patients with normal ECG and no cardiac symptoms, especially when MRI confirms an isolated lacunar infarct.
- Routine echocardiographic screening in this patient group may result in significant, potentially unnecessary, healthcare expenditures.
Background:
Stroke is a prominent and financially burdensome disease. Lacunar strokes are traditionally attributed to small vessel disease rather than cardioemboli, which typically occlude larger arteries. Thus, the benefit of screening for potential sources of cardioemboli in lacunar stroke patients is unclear. We evaluated the clinical utility of the transthoracic echocardiogram performed in patients with lacunar strokes.
Methods:
A single-center retrospective analysis of ischemic stroke patients from January 2013 through December 2017 was performed. Brain magnetic resonance imaging was used to select patients with a single lacunar infarct. Patients presenting with acute symptoms of cardiac disease or an abnormal electrocardiogram were excluded. Transthoracic echocardiogram results were reviewed, and their utility in decision-making was evaluated.
Results:
Of the 442 patients at our institution diagnosed with ischemic stroke during the inclusion period, 89 met inclusion criteria. Transthoracic echocardiogram detected a patent foramen ovale in 5.6% of patients, mitral annular calcification in 9.0% of patients, and abnormal wall motion in 4.5% of patients. For all patients, there were no findings that prompted anticoagulation, antibiotic, or surgical intervention. The cost of an inpatient transthoracic echocardiogram is $4100, resulting in $364,900 in unnecessary health care spending.
Conclusions:
Transthoracic echocardiogram appears to have minimal therapeutic value in most patients with lacunar strokes. In stroke patients with no acute symptoms of cardiac disease and a normal electrocardiogram, it may be reasonable to forgo the transthoracic echocardiogram if the brain magnetic resonance imaging shows an isolated lacunar infarct.
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