Abstract WP230: The Yield of Echocardiography in Cancer Patients with Suspected Cardioembolic Stroke

Abstract

Background: Autopsy studies demonstrate that cardioembolism from nonbacterial thrombotic endocarditis (NBTE) is a common cause of stroke in patients with cancer. Echocardiography is often used to clinically diagnose NBTE, but it has unknown yield for NBTE lesions, which are typically small and difficult to detect. Methods: We identified all patients with active cancer admitted to Memorial Sloan-Kettering Hospital from 2008 to 2010 with acute ischemic stroke who underwent transthoracic (TTE) or transesophageal echocardiography (TEE). Two neurologists independently reviewed all clinical data and classified patients as having suspected cardioembolic (CE) strokes if brain MRI showed embolic-appearing infarcts in more than one vascular territory. They also reviewed TTE and TEE reports and adjudicated whether these studies revealed a definite or possible source of stroke. Definite sources included complex aortic arch atheroma, valve vegetation, left atrial or ventricular thrombus, patent foramen ovale (PFO) with documented venous thromboembolism (VTE), severe cardiomyopathy, or cardiac tumor. Possible sources consisted of PFO without VTE, atrial septal aneurysm, dyskinetic left ventricular segment, spontaneous echo contrast, and simple aortic arch atheroma. NBTE was diagnosed if valve vegetations were seen on echocardiography, blood cultures were negative, and clinical signs of infection were absent. Results: Among 119 patients with cancer and ischemic stroke (mean age 66 [SD 13], 51% men), 99 (83%) had TTE and 16 (13%) had TEE. TTE revealed a definite source in 3 (3%) patients and a possible source in 15 (15%). Conversely, TEE revealed a definite source in 6 (38%) patients and a possible source in 5 (31%). No vegetations were seen on TTE, but 4 were discovered on TEE, all from NBTE. In 42 of 52 patients with suspected CE stroke who underwent TTE, 3 (7%) had a definite source and 8 (19%) a possible source. Eleven of these patients also underwent TEE, which demonstrated a definite or possible source in 9 (81%). Conclusions: The yield of TTE for detecting NBTE and other cardiac sources of stroke in patients with cancer is poor, but TEE may be helpful in targeted patients.