Transesophageal echocardiography (TEE) is accepted as a valuable tool in the evaluation of ischemic stroke patients, particularly in the young and in cases of unknown cause. However, the real clinical impact of additional TEE data remains to be defined.
Purpose: The aim of this study was to present our experience with TEE in ischemic stroke patients without previous evidence of a cardiac source of emboli.
Methods: From March 1991 to June 2000 we studied 172 patients (80 males, 92 females, mean age 43 +/- 12 years presenting with a transient ischemic attack or a recent cerebral infarction who had no previous evidence by clinical assessment, electrocardiogram and transthoracic echocardiography of a cardiac of emboli source. The population was divided into two groups: Group A--age < or = 45 years, n = 101 (43 males, 58 females, mean age 34 +/- 7 years) and Group B--age > 45 years, n = 71 (36 males, 35 females, mean age 54 +/- 7 years). Information was gathered from clinical records. In every case TEE included Doppler color flow imaging and multiple contrast injections (agitated saline) with and without Valsalva maneuver.
Results: A potential cardiac of emboli source was found in 29% of the patients, with a higher prevalence in the older group (group A--25%, Group B--35%, ns). Atrial septal abnormalities accounted for most of the detected findings (23 patent foramen ovale, 17 atrial septal aneurysms and two atrial septal defects, representing altogether 71% of the findings). The other detected anomalies were distributed as follows: aortic plaques--six, mitral valve prolapse--five vegetations--four, thrombus in left atrial appendage--two. Only six patients (3.5%) had abnormalities which in themselves determined a specific approach, which were found mostly in the older group (Group A--two vegetations; Group B--two vegetations, two thrombi).
Conclusions: TEE identified additional findings with possible embolic potential in a considerable number of cases, the majority of which were of a debatable cause-effect relation. A higher diagnostic yield and clinical relevance was found in older patients, which argues against age being used as a selective criterion for it. Our experience suggests that routine TEE in this setting is of questionable value and has little impact on clinical management, for which reason TEE referral should be decided on an individual patient basis.