Abstract
Background and PurposeIndication of transesophageal echocardiography (TEE) in patients ≤60 years with brain ischemia is uncertain.MethodsThis prospective double-blinded study included patients with cryptogenic acute ischemic stroke or transient ischemic attack (TIA) ≥18 and ≤60 years. After routine diagnostics, all patients underwent patent foramen ovale (PFO) screening by transcranial Doppler (TCD) bubble test, carotid ultrasound for atherosclerosis screening (intima-media-thickness >0.90 mm or plaques), and TEE. We calculated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) of the combined non-invasive ultrasound to predict therapy-relevant TEE findings.ResultsWe included 240 consecutive patients (median 51 years, 39% women) of which 68 (28.3%) had both a negative bubble test and no carotid atherosclerosis. Of these, 66 (97.1%) had unremarkable TEE findings; in one patient a small PFO was found and closed subsequently, in another patient a 4.9 mm thick aortic atheroma was found, and double platelet inhibition initiated. Of the other 172 (71.7%) patients, 93 (54%) had PFO and 9 (5.2%) complex aortic plaques. No other therapy-relevant findings were present in both groups. Non-invasive ultrasound had a sensitivity of 98.0%, specificity of 47.8%, NPV of 97.1%, and PPV of 58.1% for therapy-relevant TEE findings.ConclusionsBubble test and carotid ultrasound could be used for the individual decision for/against TEE in patients with cryptogenic stroke ≤60 years. If they are unremarkable, TEE can be omitted with high safety regarding secondary prevention. If bubble test is positive and/or carotid ultrasound shows atherosclerosis, TEE should be carried out if PFO or aortic atheroma are potentially relevant for further patient management.
Highlights
Detailed diagnostic work-up for the identification of stroke etiology is crucial to optimize secondary prevention and avoid recurrent brain ischemia
Routine diagnostics comprised of comprehensive assessment of medical history, physical examination, brain imaging with CT and/or MRI, vascular imaging of extra-and intracranial arteries by CT- or magnetic resonance (MR)-angiography or 2D carotid duplex sonography, 12-lead- and >24 h Holter- or monitorECG, routine laboratory tests, and transthoracic echocardiography (TTE) [we did not assess for patent foramen ovale (PFO) on TTE due to its low sensitivity [19]]
Transesophageal echocardiography was performed within 1 day in 203 (84.6%) and within 2 days of non-invasive ultrasound in 228 (95%) of the patients
Summary
Detailed diagnostic work-up for the identification of stroke etiology is crucial to optimize secondary prevention and avoid recurrent brain ischemia. Even after comprehensive diagnostics, stroke etiology remains cryptogenic in 22–43% of patients [1–3]. In such cases, transesophageal echocardiography (TEE) can be helpful to detect further cardiac or aortic sources of brain embolism [4–7]. Transesophageal echocardiography findings in patients with stroke differ significantly between age groups. In patients under 60 years, TEE shows mainly patent foramen ovale (PFO) and infrequently complex aortic plaques while other embolic sources are very rare [8, 9]. The benefit of TEE in young patients with stroke lies in the detection of PFO and, in fewer cases, complex aortic plaques. Indication of transesophageal echocardiography (TEE) in patients ≤60 years with brain ischemia is uncertain
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