Abstract
BackgroundPatients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause often undergo cardiac imaging in search of a cardioembolic source. As the choice of the most appropriate imaging approach is controversial and therapeutic implications have changed over time, we aimed to identify in patients with “cryptogenic stroke or TIA” the yield of transthoracic or transesophageal echocardiography (TTE or TEE) and cardiac computed tomography (CT). Methods and resultsWe performed a systematic review and meta-analysis according to the PRISMA guidelines. Included were studies that assessed consecutive patients with ischemic stroke or TIA of undetermined cause to evaluate the yield of TTE, TEE, or cardiac CT for detecting cardioembolic sources. For each type of cardioembolic source the pooled prevalence was calculated. Only six out of 1458 studies fulfilled the inclusion criteria (1022 patients). One study reported the yield of TTE, four of TEE, and one of both TTE and TEE; no study assessed cardiac CT. Mean patient age ranged from 44.3–71.2 years, 49.2–59.7% were male. TTE detected 43 cardioembolic sources in 316 patients (4 (1.3%) major, 39 (12.3%) minor), and TEE 248 in 937 patients (55 (5.9%) major, 193 (20.6%) minor). The most prevalent major cardioembolic source was left atrial appendage thrombus, yet results were heterogeneous among studies. ConclusionsTTE and TEE infrequently detect major cardioembolic sources that require a change of therapy. Findings should be interpreted with caution due to the limited number of studies. A large-sized prospective clinical trial is warranted to support evidence-based decision-making.
Highlights
After an ischemic stroke or transient ischemic attack (TIA), generally there is a diagnostic work-up in search of the cause of the event, as this information may guide treatment that aims at reducing the risk of recurrent ischemic events [1,2]
For each study we evaluated at which point in the stroke work-up patients were included and planned to perform subgroup analyses based on criteria for ischemic stroke of undetermined cause and age groups of patients below 50 years or 50 years and older
For this systematic review and meta-analysis, we aimed at investi gating in patients with ischemic stroke of undetermined cause the yield of echocardiography and cardiac computed tomography (CT) for detecting cardioembolic sources
Summary
After an ischemic stroke or transient ischemic attack (TIA), generally there is a diagnostic work-up in search of the cause of the event, as this information may guide treatment that aims at reducing the risk of recurrent ischemic events [1,2]. Despite a routine in-hospital diagnostic work-up that generally consists of imaging of the brain and carotid arteries, laboratory testing, electrocardiogram (ECG), and at least 24 h of cardiac rhythm moni toring, the underlying cause remains unknown in about 25% of patients [4]. In these patients, the event is referred to as “cryptogenic stroke” or “ischemic stroke of undetermined cause”. Included were studies that assessed consecutive patients with ischemic stroke or TIA of undetermined cause to evaluate the yield of TTE, TEE, or cardiac CT for detecting cardioembolic sources. A large-sized prospective clinical trial is warranted to support evidence-based decision-making
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