The Effect of Transoesophageal Echocardiography on Treatment Change in a High-Volume Stroke Unit.

Camille Siegel,Corina Mirea,Valérie Wolff,Patrick Ohlmann,Floriane Zeyons,Marilou Peillex,Laurence Jesel,Benjamin Marchandot,Kensuke Matsushita,Antonin Trimaille,Helene Petit-Eisenmann,François Sauer,Olivier Rouyer,Cecile How-Choong,Olivier Morel,Annie Trinh

doi:10.3390/jcm10040805

Abstract

Background and purpose—current guidelines recommend the use of transesophageal echocardiography (TEE) in relation to cardio-embolic sources of stroke. Methods—by using an hospital-based cohort, we retrospectively analyzed consecutive patients with acute ischemic stroke (AIS), acute hemorrhagic stroke (AHS) and transient ischemic attack (TIA) who were admitted in Strasbourg Stroke Center, France between November 2017 to December 2018. TEE reports were screened for detection of potential cardiac sources of embolism and the subsequent change in medical management. We performed univariate and multivariate analyses to identify predictors of relevant TEE findings. Results-out of the 990 patients admitted with confirmed stroke, 432 patients (42.6%) underwent TEE. Patients with TEE were younger (62.8 ± 14.8 vs. 73.8, p < 0.001), presented less comorbidities and lower stroke severity assessed by lower NIHSS (2 IQR (0–4) vs. 3 IQR (0–10), p < 0.01) and Modified Rankin Scale (1 IQR (0–1) vs. 1 (0–3), p < 0.01). A total of 227 examinations (52.5%) demonstrated abnormal findings considered as potential cardiac sources of embolism and 31 examinations (7.1%) were followed by subsequent change in medical management. Age (HR: 0.948, 95% CI 0.923 to 0.974; p < 0.001), previous AIS (HR: 3.542, 95% CI 1.290 to 9.722; p = 0.01), previous TIA (HR: 7.830, CI 95% 2214 to 27,689; p = 0.001) and superficial middle cerebral artery territory infarction (HR: 2.774, CI 95% 1.168–6.589; p = 0.021) were strong independent predictors with change in medical management following TEE. Conclusions—additional TEE changed the medical course of stroke patients in 7.1% in a French high-volume stroke unit.

Highlights

Together with discrepancies in routine clinical practice [6], the role of Transesophageal Echocardiography (TEE) in identifying ischemic stroke etiology remains complex and is a matter of ongoing debate [7]. New scoring systems such as the ADAM-C score [8] have tried to better identify patients who are likely to benefit from TEE in stroke units
Updated European and American guidelines have addressed the use of transesophageal echocardiography (TEE) in the field of stroke
More studies are necessary to better identity patients who are likely to benefit from TEE in stroke units

Summary

Introduction

Stroke is the third leading cause of death and the leading cause of serious and longterm disability in industrialized countries. With 87% of all strokes of ischemic origin, the. Trial of Org 10172 in Acute Stroke Treatment criteria [1] has subdivided acute ischemic stroke (AIS) into 5 subgroups—(i) thrombosis or embolism associated with large vessel atherosclerosis, (ii) cardio-embolic stroke, (iii) lacunar stroke, (iv) other determined cause and (v) cryptogenic cause. New high-quality imaging techniques have produced major changes in the evidence-based treatment of each subgroup of AIS and latest updates from the American Heart Association/American Stroke Association in 2019 recommended echocardiography as a class IIa recommendation to guide patient and treatment selection [2]. As cardio-embolic stroke accounts for 15–30% of AIS [3], the identification of a potential cardiac source of embolism is of paramount importance and both transthoracic (TTE)

Methods

Results

Conclusion