Transoesophageal Echocardiography in Patients without Arterial and Major Cardiac Sources of Embolism: Difference between Stroke Subtypes

Abstract

We studied the records of 175 consecutive patients referred to our neurologic ward between January 1994 and February 2000 with a diagnosis of ischaemic cerebrovascular disease (ICVD) (stroke or transient ischaemic attack – TIA) who underwent transoesophageal echocardiography (TEE). We excluded patients with large vessel disease, high-risk embolic cardiopathies and other rare causes of stroke. According to clinical and neuroimaging findings, patients were divided into two groups. The lacunar (LAC) group (69/175 (39.4%)) and the nonlacunar (N-LAC) one (106/175 (60.6%)). The control population consisted of 78 consecutive patients, referred to the echocardiography laboratory for TEE without history of ICVD and known heart disorders. Patent foramen ovale (PFO) frequency was significantly higher in case patients than in control subjects (55/175 (31.4%) vs. 13/78 (16.6%); p = 0.02). Among case patients, PFO was more prevalent in the N-LAC group than in the LAC one (43/106 (40.6%) vs. 12/69 (17.4%); p = 0.0005). A large degree of shunt occurred in 53.5% of N-LAC patients and in 16.7% of LAC ones (p = 0.04). Atrial septal aneurysm (ASA) was detected in 12% of case patients and 1.3% of control subjects (p = 0.003) and was more frequent in the N-LAC group than in the LAC one (16 vs. 5.8%; p = 0.05). Mitral prolapse (MP) was present in 6/175 (3.4%) ICVD patients (vs. 1/78 among controls) in most cases associated with myxomatous valve redundancy. Aortic arch atheromas (AA) were detected in 12% of ICVD patients and in 10.2% of controls. The frequency was 9.4% in N-LAC and 15.9 in LAC. No complicated AA (plaque thickness >4 mm, ulcerated atheroma, superimposed thrombus) were detected. After multivariate analysis, PFO (OR = 3.8; 95% CI = 2.7–7.9) and ASA (OR = 8.01; 95% CI = 3.0–16.1) appeared to be independent predictors of ICVD. PFO (OR = 2.24; 95% CI = 1.24–4.92) was also independently associated with N-LAC stroke subtype and its importance was even higher in younger patients. Our study provides further evidence that TEE is a helpful diagnostic tool in stroke patients without arterial and major cardiac sources of embolism. However, its utility differs according to type and localization of the ischaemic lesion being more relevant in patient with N-LAC infarctions.

Recurrent cerebrovascular ischaemic events in patients with interatrial septal abnormalities: a follow-up study

“…In patients with stroke or TIA without arterial and major cardiac sources of embolism in a previous work we found a frequency of PFO of 31.4% that rose to 40.6% in patients with non-lacunar (presumably embolic) stroke/TIA [13]. Reported rates of PFO occurrence in patients with cryptogenic stroke range from 31 to 77% [1].…”

“…All patients underwent transthoracic and transoesophageal echocardiography, performed by experienced cardiologists according to the protocol reported in our previous study [13]. Examinations were recorded on videotape and reviewed by two independent examiners unaware of the patients' clinical data and outcome.…”

“…According to our previous work [13] and to other Authors [15][16][17], the entity of the right-left shunt was defined "small" if less than 20 microbubbles appeared in the left atrium upon release of a Valsalva manoeuvre and "large" if at least 20 microbubbles appeared after Valsalva or if a right to left shunt was evident at rest. An ASA was diagnosed when the atrial septum extended at least for 11 mm either into the left or the right atrium or both.…”

Definition and Evaluation of Transient Ischemic Attack

“…Atrial septal aneurysm was more frequent, especially with nonlacunar stroke. 165 Patient age and topography of the ischemic event did not correlate with the type of cardioembolic source (ie, PFO, left atrial clot, or aortic arch atheroma). 159 It is common for significant cardiac and carotid lesions to coexist.…”

Prevalence of aneurysm of the interatrial septum in the general population and in patients with a recent episode of cryptogenetic ischemic stroke: a tissue harmonic imaging transthoracic ecocardiography study in 5.631 patients

“…Valutando cumulativamente otto studi su popolazioni non selezionate [13,19,[25][26][27][28][29][30], eseguiti con ETE dal 1991 al 2000, si osserva una prevalenza media di ASA del 5.7% (tabella 1); la prevalenza sale al 19% se si considerano solo gli esami ETE eseguiti per ricercare fonti cardioemboliche (tabella 2) [13,19,25,31,32].…”