Utility of Transesophageal Echocardiography in the Identification and Treatment of Occult Mechanisms of Cerebral Infarction

Abstract PurposeTo evaluate the diagnostic utility of TEE in identifying cardiac sources of embolism (CSE) in cryptogenic stroke patients and to determine whether the identification of these CSE results in clinically significant management changes. MethodsA prospective registry of consecutively admitted patients with acute ischemic stroke (1/1/2015-8/10/2020) was retrospectively queried. Patients 18 to 60 years of age with stroke due to mechanisms other than large or small vessel disease, or atrial fibrillation were eligible for inclusion. The primary outcome was any high-risk CSE identified on TEE following unrevealing TTE. Secondary outcomes included a composite of individual CSEs and subsequent management changes. ResultsOf the 2,404 consecutive stroke patients evaluated during the study period, 263 (11%) met inclusion criteria; 103 (39%) were women and the median age was 53 (IQR 46-57). TEE was performed in 108 patients (41%). A high-risk CSE was identified in 36 patients (33%), the majority of which were PFOs (n=29). TEE led to a clinical management change in 14 patients (39%) after identification of a high-risk CSE; 6 underwent PFO closure and 8 had adjustment to their antithrombotic therapy. ConclusionIn our single-center study of cryptogenic stroke patients, the addition of TEE to the comprehensive stroke evaluation led to the identification of a high-risk CSE in one in three patients resulting in significant management changes. Most high-risk CSEs were PFOs, which likely underestimates the likelihood of management change given the publication of successful PFO closure trials in the middle of our study period.