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[Evaluation of embolic cerebrovascular complication: contribution of transesophageal echography]
A Millaire1, L Goullard, E Chammas
1Service de Cardiologie, Hôpital Cardiologique de Lille.
Insights
Trans-esophageal echocardiography (TEE) reveals cardiac anomalies in over 50% of ischemic stroke patients, questioning traditional embolism theories. Routine TEE is suggested for young stroke patients without apparent heart disease.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Ischemic cerebrovascular accidents are traditionally attributed to cardiac embolism in 15% of cases.
- Trans-esophageal echocardiography (TEE) challenges this longstanding concept by identifying a higher incidence of potential embolic sources.
Purpose of the Study:
- To evaluate the diagnostic yield of TEE in identifying cardiac anomalies associated with ischemic cerebrovascular accidents.
- To assess the superiority of TEE over trans-thoracic echocardiography (TTE) in detecting specific cardiac abnormalities.
- To propose recommendations for the investigation of ischemic cerebrovascular accidents, particularly in young patients.
Main Methods:
- Review of studies utilizing trans-esophageal echocardiography (TEE) for the investigation of ischemic cerebrovascular accidents.
- Comparison of TEE findings with trans-thoracic echocardiography (TTE) in identifying cardiac abnormalities.
- Analysis of the incidence of specific anomalies like intra-atrial thrombus, spontaneous atrial contrast, aortic plaques, patent foramen ovale, and atrial septal aneurysms.
Main Results:
- TEE identified potential embolic sources in over 50% of cases in certain series, significantly higher than previously assumed.
- TEE demonstrated superiority over TTE in detecting various abnormalities, including intra-atrial thrombus, spontaneous atrial contrast, and patent foramen ovale.
- High incidence of abnormalities necessitates further studies to establish causality and stratify embolic risk.
Conclusions:
- Trans-esophageal echocardiography is a valuable tool for investigating ischemic cerebrovascular accidents, revealing a high prevalence of cardiac anomalies.
- The routine use of TEE is recommended for young patients with ischemic cerebrovascular accidents, even in the absence of clinically evident heart disease or a normal TTE.
- Further research is required to determine the causal relationship between identified abnormalities and embolic events, and to refine risk stratification.
Abstract:
Ischemic cerebrovascular accidents are classically attributed to an embolism of cardiac origin in 15% of cases. This longstanding concept is questioned by trans-esophageal echocardiography (TEE). The incidence of anomalies which could be the origin of a cerebral embolism involves more than 50% of cases in certain series. The superiority of TEE over trans-thoracic echocardiography (TTE) emerges in particular when certain abnormalities such as an intra-atrial thrombus, spontaneous atrial contrast, an intra-aortic atherosclerotic plaque, a patent foramen ovale or an aneurysm of the inter-atrial septum are sought. The high incidence of such abnormalities in a population having sustained an ischemic cerebrovascular accident is not sufficient to establish a cause-and-effect relationship between the abnormality and the cerebral event. Certain abnormalities are commonly associated with each other or with emboligenic arrhythmias (atrial fibrillation). Studies hence remain required to determine the respective responsibilities of these various abnormalities and stratify their embolic risk by defining certain risk factors. While awaiting the result of such studies, it would seem valid to suggest the more routine use of TEE in the investigation of ischemic cerebrovascular accidents in young patients free of clinically obvious heart disease, and this regardless of the result of TTE.