The role of transesophageal echocardiopgraphy in detection of cardiogenic and aortic sources of embolism in stroke and transient ischaemic attacks
Authors:
J. Dúbrava 1; R. Garay 2
Authors‘ workplace:
Oddelenie funkčnej diagnostiky FNsP Bratislava, pracovisko Petržalka, Slovenská republika, prednosta prim. MUDr. Juraj Dúbrava, Ph. D.
1; Neštátne neurologické oddelenie, NEURÓN PLUS, s. r. o., Bratislava, Slovenská republika, prednosta prim. MUDr. Róbert Garay, CSc.
2
Published in:
Vnitř Lék 2006; 52(2): 144-151
Category:
Original Contributions
Overview
Objectives:
To prospectively investigate the prevalence of definite and potential sources of cardiogenic embolism and embolism from ascending aorta and aortic arch in patients with a cryptogenic stroke or transient ischaemic attack (TIA).
Material/methods:
The study group consisted of 218 consecutive patients (146 males, mean age 59.4 ± 11.5, range 38 - 83 years) without significant stenoses of carotic and vertebral arteries. All patients underwent biplane/multiplane transesophageal echocardiography (TEE). 77.5 % of patients suffered a stroke and 22.5 % had a TIA. Sinus rhythm was in 74.8 % of the patients, atrial fibrillation in 22.0 % and pacemaker rhythm in 3.2 %.
Results:
1. Definite source of embolism was identified in 21.6 % of patients. The most frequent finding was a thrombus of the left atrial (LA) appendage - 12.4 %. Less frequently found were mobile thrombus of aortic arch - 3.7 %, thrombus of LA body - 2.3 %, left ventricular thrombus - 2.3 %, thrombus of valvular prosthesis - 1.4 % and heart tumor - 0.5 %. 2. The total prevalence of potential sources of embolism was 61.5 %. Only potential source (without definite source) was demonstrated in 52.3 % of patients. Very frequently were found patent foramen ovale - 58.3 % and atherosclerosis of ascending aorta or aortic arch - 53.7 %. Further sources were LA spontaneous echocontrast - 21.1 %, reduced function of LA appendage - 18.3 %, atrial septal aneurysm - 7.8 %, atrial septal defect - 1.4 %, cardiac foreign body - 0.5 %. 3. TEE did not reveal any source of embolism in 26.1 % of patients.
Conclusions:
1. 21.6 % of the patients suffering from stroke/TIA without hemodynamically significant stenoses of extracranial cerebral arteries had a definite cardiogenic or aortic source of embolism, 2. additional 52.3 % of patients had only potential source of embolism (without definite source), 3. we consider TEE necessary in patients with stroke/TIA without a known etiology, despite complete neurological examination and transthoracic echocardography.
Key words:
stroke - transient ischaemic attack - cardiogenic embolism - aortic source of embolism - transesophageal echocardiography
Sources
1. 21,6 % pacientov s LIM/TIA bez hemodynamicky významných stenóz na extrakraniálnych mozgových tepnách malo definitívny kardiogénny alebo aortálny zdroj embolizácie.
2. Ďalších 52,3 % pacientov malo len potenciálny zdroj embolizácie (bez definitívneho zdroja).
3. TEE považujeme za potrebné, ak neurologické vyšetrenie vrátane ultrasonografie extrakraniálnych mozgových tepien a TTE nevysvetlia príčinu LIM/TIA.
Literatúra
1. Petty GW, Brown RD Jr, Whisnant JP et al. Ischemic stroke subtypes : a population-based study of functional outcome, survival, and recurrence. Stroke 2000; 31: 1062-1068.
2. Becker EI, Jung A, Voller H et al. Cardiogenic embolism as the main cause of ischemic stroke in a city hospital: an interdisciplinary study. Vasa 2001; 30: 43-52.
3. Kelley RE, Minagar A. Cardioembolic stroke: an update. South Med J 2003; 96: 343-349.
4. Arboix A, Vericat MC, Pujades R et al. Cardioembolic infarction in the Sagrat Cor-Alianza Hospital of Barcelona Stroke Registry. Acta Neurol Scand 1997; 96: 407-412.
5. Garay R. Kardioembolický infarkt mozgu z pohľadu neurológa. Kardiol prax 2003; 1: 63-68.
6. Chen EW, Redberg RF. Echocardiographic evaluation of the patient with a systemic embolic event. In: Otto CM The practice of clinical echocardiography. Philadelphia: WB Saunders 2002: 806-828.
7. The French Study of Aortic Plaques in Stroke Group. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med 1996; 334: 1216-1221.
8. Goldman M, Kronzon I, Goldstein S et al. Value of transesophageal echocardiography: results in 3,001 patients (abstract). Circulation 1994; 90: 120.
9. Palazzuoli A, Ricci D, Lenzi C et al. Transesophageal echocardiography for identifying potential cardiac sources of embolism in patients with stroke. Neurol Sci 2000; 21: 195-202.
10. Yahia AM, Shaukat AB, Kirmani JF et al. Treatable potential cardiac sources of embolism in patients with cerebral ischemic events: a selective transesophageal echocardiographic study. South Med J 2004; 97: 1055-1059.
11. Rauh R, Fischereder M, Spengel FA. Transesophageal echocardiography in patients with focal cerebral ischemia of unknown cause. Stroke 1996; 27: 691-694.
12. Sorescu D, Turk RJ, Cain M et al. Clinical and transthoracic echocardiographic predictors of abnormal transesophageal findings in patients with suspected cardiac source of embolism. Am J Med Sci 2003; 326: 31-34.
13. Wolf PA, Abbott RD, Kannel WB Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22: 983-988.
14. Bornstein N, Corea F, Galllai V et al. Heart-brain relationship: atrial fibrillation and stroke. Clin Exp Hypertens 2002; 24: 493-499.
15. Toman J. Nitrosrdeční útvary a zdroje embolií. In: Niederle P et al. Echokardiografie. 1. díl - Echokardiografie dospělých. Praha: Triton 2002: 257-267.
16. Stöllberger C, Brainin M, Abzieher F et al. Embolic stroke and transoesophageal echocardiography: can clinical parameters predict the diagnostic yield? J Neurol 1995; 242: 437-442.
17. Foniakin AV, Geraskina LA, Suslina ZA. Echocardiographic changes associated with risk of developing embolic complications in patients with ischemic stroke. Ter Arkh 2002; 74: 71-74.
18. Benetka O, Block M, Sangha O et al. Clinical course of infective endocarditis in the late nineties: preliminary results of the ALKK endocarditis registry. Eur Heart J 1999; 20: 362.
19. Lee RJ, Bartzokis T, Yeoh TK et al. Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography. Stroke 1991; 22: 734-739.
20. Comess KA, DeRook FA, Beach KW et al. Transesophageal echocardiography and carotid ultrasound in patients with cerebral ischemia: prevalence of findings and recurrent stroke risk. J Am Coll Cardiol 1994; 23: 1598-1603.
21. Serafini O, Misuraca G, Greco F et al. Prevalence of structural abnormalities of the atrial septum and their association with recent ischemic stroke or transient ischemic attack: echocardiographic evaluation in 18631 patients. Ital Heart J Suppl 2003; 4: 39-45.
22. Cerrato P, Grasso M, Imperiale D et al. Stroke in young patients: etiopathogenesis and risk factors in different age classes. Cerebrovasc Dis 2004; 18: 154-159.
23. Mattioli AV, Aquilina M, Oldani A et al. Frequency of atrial septal aneurysm in patients with recent stroke: preliminary results from a multicenter study. Clin Cardiol 2001; 24: 297-300.
24. Steiner MM, Di Tullio MR, Rundek T et al. Patent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke. Stroke 1998; 29: 944-948.
25. Beattie JR, Cohen DJ, Manning WJ et al. Role of routine transthoracic echocardiography in evaluation and management of stroke. J Intern Med 1998; 243: 281-291.
26. Cujec B, Mainra R, Johnson DH. Prevention of recurrent cerebral ischemic events in patients with patent foramen ovale and cryptogenic strokes or transient ischemic attacks. Can J Cardiol 1999; 15: 57-64.
27. Mattioli AV, Bonetti L, Aquilina M et al. Association between atrial septal aneurysm and patent foramen ovale in young patients with recent stroke and normal carotid arteries.
Cerebrovasc Dis 2003; 15: 4-10.
28. Cerrato P, Imperiale D, Priano L et al. Transoesophageal echocardiography in patients without arterial and major cardiac sources of embolism: difference between stroke subtypes. Cerebrovasc Dis 2002; 13: 174-183.
29. Agmon Y, Khandheria BK, Meissner I et al. Frequency of atrial septal aneurysms in patients with cerebral ischemic events. Circulation 1999; 99: 1942-1944.
30. Dúbrava J. Foramen ovale patens. 1. časť - Epidemiológia, klinický význam a diagnostika. Kardiol prax 2004; 2: 166-171.
31. Melcon CM, Rotta-Escalante R, Curatolo LM et al. Ischemic stroke: transesophageal echocardiographic findings. Rev Neurol 2003; 36: 330-334.
32. Matsumura Y, Osaki Y, Fukui T et al. Protruding atherosclerotic aortic plaques and dyslipidaemia: correlation to subtypes of ischaemic stroke. Eur J Echocardiogr 2002; 3: 8-12.
33. Blum A, Reisner S, Farbstein Y Transesophageal echocardiography (TEE) vs. transthoracic echocardiography (TTE) in assessing cardio-vascular sources of emboli in patients with acute ischemic stroke. Med Sci Monit 2004; 10: CR521-523.
34. Boon A, Lodder J, Cheriex E et al. Mitral annulus calcification is not an independent risk factor for stroke: a cohort study of 657 patients. J Neurol 1997; 244: 535-541.
35. Meissner I, Whisnant JP, Khandheria BK et al. Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: the SPARC study. Stroke Prevention: Assessment of Risk in a Community. Mayo Clin Proc 1999; 74: 862-869.
36. Roijer A, Lindgren A, Rudling O et al. Potential cardioembolic sources in an elderly population without stroke. A transthoracic and transoesophageal echocardiographic study in randomly selected volunteers. Eur Heart J 1996; 17: 1103-1111.
37. Cheitlin MD, Armstrong WF, Aurigemma GP et al. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108: 1146-1162.
38. Kapral MK, Silver FL. Preventive health care. 1999 update: 2. Echocardiography for the detection of a cardiac source of embolus in patients with stroke. Canadian Task Force on Preventive Health Care. CMAJ 1999; 161: 989-996.
39. McNamara RL, Lima JA, Whelton PK et al. Echocardiographic identification of cardiovascular sources of emboli to guide clinical management of stroke: A cost-effectiveness analysis. Ann Int Med 1997; 127: 775-787.
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