Diagnostic Yield of TEE in Patients with Cryptogenic Stroke and TIA with Normal TTE: A Systematic Review and Meta-Analysis

Abstract

Introduction: The role of transesophageal echocardiography (TEE) in cryptogenic stroke and transient ischemic attack (TIA) with normal transthoracic echocardiography (TTE) remains controversial in the absence of definite guidelines. We aimed to perform a systematic review and meta-analysis to estimate an additional diagnostic yield and clinical impact of TEE in patients with cryptogenic stroke and TIA with normal TTE. Methods: We performed a systematic review of cohort studies on PubMed using the keywords ‘cryptogenic stroke’, cryptogenic TIA’, ‘TEE’, and ‘TTE’ with matching MeSH terms. We included studies with patients who had cryptogenic stroke or TIA and had normal TTE findings, where the study intended to obtain TEE on all patients and reported all TEE abnormalities. The studies containing patients with atrial fibrillation were excluded. All studies were evaluated for internal and external validity. Inverse variance random effects models were used to calculate the effect size, the number needed to diagnose, and the 95% confidence interval. Results: We included 15 studies with 2054 patients and found LA/LAA/aortic thrombus, valvular vegetation, PFO-ASA, valvular abnormalities, and complex aortic plaques on TEE. Of these, 37.5% (29.7%–45.1%) of patients had additional cardiac findings on TEE. Management of 13.6% (8.1%–19.1%) of patients had changed after TEE evaluation. Based on current guidelines, it should change management in 4.1% (2.1%–6.2%) of patients and could potentially change management in 30.4% (21.9%–38.9%) of patients. Sensitivity analysis was also performed with only class II studies to increase internal validity, which showed additional cardiac findings in 38.4% (28.5%–48.3%), changed management in 20.2% (8.7%–31.8%), should change management in 4.7% (1.5%–7.9%), and could potentially change management in 30.4% (17.8%–43.0%) of patients. Conclusions: The diagnostic yield of TEE to find any additional cardiac findings in patients with cryptogenic stroke or TIA is not only high, but it can also change management for certain cardiac abnormalities. TTE in cryptogenic stroke or TIA may mitigate future risks by tailoring the management of these patients.

Clinical Study of Clopidogrel Combined with Huoxue Tongluo Prescription in Improving Transient Ischemic Attack and the Effect on MMP-9, Hcy, and CRP

“…TIA, a common cerebrovascular disease, is a neurological disorder caused by focal and transient cerebral ischemia, and its clinical manifestations are unclear speech expression, transient nystagmus, reduced vision, tinnitus, unstable standing or walking, and vertigo [10]. Modern medical research believes [11][12][13] that the onset of TIA is related to the formation of carotid atherosclerotic plaque, high cholesterol, and abnormal hemodynamics. e basic pathological changes of TIA are insufficient blood supply to the brain tissue, which can affect the normal function of nerve cells.…”

Diagnostic Evaluation of Stroke Etiology

“…For example, patients with known atrial fibrillation and a moderate to high CHA 2 DS 2 -VASc score need long-term oral anticoagulation regardless of whether a thrombus is identified by echocardiography in the left atrium, left atrial appendage, or aorta. TEE is generally considered more sensitive and specific than transthoracic echocardiogram (TTE) for detecting sources of cardioembolism, but the discovery of pathologies that should alter management occurs in less than 5% of cases 28 . TEE, the more invasive test, may be less effective in detecting patent foramen ovale than TTE with contrast and the Valsalva maneuver 29 …”

Recent advances in the management of transient ischemic attacks

“…At present, comprehensive cardiac imaging can be accomplished by transthoracic (TTE) or transesophageal (TEE) echocardiography or both ( Table 2 ). These two complementary approaches to ultrasonic cardiac imaging provide both morphologic and functional information about cardiac performance, uncovering abnormalities that must be factored in during risk stratification ( Table 2 ), and TTE favors the evaluation of left ventricular contractility, mitral valve performance, left atrial volume, and the possible presence of right-to-left shunts 71 , 72 . By contrast, TEE offers increased resolution and sensitivity for left atrial pathology, including the left atrial appendage (LAA) and the interatrial septum; TEE also can provide information about the aortic arch and the potential presence of complex atherosclerotic plaques as a source of artery-to-artery cerebral embolism ( Table 2 ).…”

“…Cardiac CT or MRI may also complement or replace ultrasound-based cardiac assessment in the future, at least in selected populations. Incorporation of this cardiac imaging data into the patient’s risk stratification will facilitate the development of a management plan tailored to the specific patient 71 , 72 . Additionally, prolonged cardiac monitoring for intervals longer than 30 days, particularly using implantable loop recorders, has increased the detection of paroxysmal arrhythmias, particularly occult atrial fibrillation 73 – 76 .…”