Original Article

Treatable Potential Cardiac Sources of Embolism in Patients with Cerebral Ischemic Events: A Selective Transesophageal Echocardiographic Study

Authors: Abutaher M. Yahia, MD, Aasma B. Shaukat, MD, MPH, Jawad F. Kirmani, MD, Andrew Xavier, MD, Nancy G. Manalio, RN, Adnan I. Qureshi, MD

Abstract

Objectives: To characterize cardiac sources of emboli detected by transesophageal echocardiography (TEE) in patients without recognizable cause of transient ischemic attack (TIA) and/or ischemic stroke and TIA.


Methods: We examined a prospective registry that included all patients with TIA and/or stroke evaluated by TEE between July 2000 and August 2001 at our medical center. Ischemic events were classified according to clinical and neuroimaging findings as cortical, lacunar, or vertebrobasilar circulation. Demographic, clinical, neuroimaging, and echocardiographic characteristics were studied.


Results: TEE was performed in 237 patients without recognized cause of TIA and/or stroke, of which 105 (44%) events were cortical, 35 (15%) were lacunar, 32 (14%) were vertebrobasilar, and 65 (27%) were in multiple distributions. Mean age of patients was 59 ± 14 years (range, 21 to 93 years); 119 (51%) were men. Potential treatable cardioembolic sources were detected in 146 (61%) patients: patent foramen ovale with right-to-left shunt (n = 59), left atrial clot (n = 6), left atrial appendage clot (n = 8), and severe thoracic aortic atherosclerotic plaque disease (plaque thickness >4 mm) (n = 79 patients [33%], 56 had an ulcerated plaque and 4 had mobile plaque). Patient age and topography of the ischemic event did not correlate with TEE-defined cardioembolic sources.


Conclusions: TEE identified high frequencies of potential treatable cardioembolic sources in patients with ischemic events. TEE should be considered in all patients who do not have identified cause of TIA and/or stroke for early treatment and prevention of recurrent events.


Key Points


* Detection of potential sources of thromboembolism following a cerebral ischemic event continues to be a challenge in the care of stroke patients, yet is of paramount importance for the prevention of subsequent episodes.


* TEE identifies high frequencies of potential treatable cardioembolic sources in patients with ischemic events.


* TEE should be considered in all patients without an identified cause of TIA and/or stroke for early treatment and prevention of recurrent events.

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References

1. Broderick J, Brott T, Kothari R, et al. The Greater Cincinnati/Northern Kentucky Stroke Study: preliminary first-ever and total incidence rates of stroke among blacks. Stroke 1998;29:415–421.
 
2. Kissela B, Broderick J, Woo D, et al. Greater Cincinnati/Northern Kentucky Stroke Study: volume of first-ever ischemic stroke among blacks in a population-based study. Stroke 2001;32:1285–1290.
 
3. Albers GW, Comess KA, DeRook FA, et al. Transesophageal echocardiographic findings in stroke subtypes. Stroke 1994;25:23–28.
 
4. Archer SL, James KE, Kvernen LR, et al. Role of transesophageal echocardiography in the detection of left atrial thrombus in patients with chronic nonrheumatic atrial fibrillation. Am Heart J 1995;130:287–295.
 
5. Asinger RW, Herzog CA, Dick CD. Echocardiography in the evaluation of cardiac sources of emboli: the role of transthoracic echocardiography. Echocardiography 1993;10:373–396.
 
6. Bussiere JP, Bonnet D, Renard JL, et al. Contribution of transesophageal echocardiography in the investigation of the atrium in systemic embolism. Ann Med Interne 1992;143:5–10.
 
7. Pearson AC. Transthoracic echocardiography versus transesophageal echocardiography in detecting cardiac sources of embolism. Echocardiography 1993;10:397–403.
 
8. Pollick C, Taylor D. Assessment of left atrial appendage function by transesophageal echocardiography: implications for the development of thrombus. Circulation 1991;84:223–231.
 
9. Vigna C, Russo A, De Rito V, et al. Frequency of left atrial thrombi by transesophageal echocardiography in idiopathic and in ischemic dilated cardiomyopathy. Am J Cardiol 1992;70:1500–1501.
 
10. Ozeren A, Acarturk E, Sarica Y, et al. Transesophageal echocardiography in various ischemic stroke subtypes. Jpn Heart J 1997;38:199–206.
 
11. Di Tullio MR, Sacco RL, Savoia MT, et al. Aortic atheroma morphology and the risk of ischemic stroke in a multiethnic population. Am Heart J 2000;139:329–336.
 
12. Mahagney A, Sharif D, Weller B, et al. Diagnosis of cerebral embolism by transesophageal echocardiography. Harefuah 1998;134:256–259.
 
13. Rundek T, Di Tullio MR, Sciacca RR, et al. Association between large aortic arch atheromas and high-intensity transient signals in elderly stroke patients. Stroke 1999;30:2683–2686.
 
14. Sen S, Wu K, McNamara R, et al. Distribution, severity and risk factors for aortic atherosclerosis in cerebral ischemia. Cerebrovasc Dis 2000;10:102–109.
 
15. Stern A, Tunick PA, Culliford AT, et al. Protruding aortic arch atheromas: risk of stroke during heart surgery with and without aortic arch endarterectomy. Am Heart J 1999;138:746–752.
 
16. Ferrari E, Vidal R, Chevallier T, et al. Atherosclerosis of the thoracic aorta and aortic debris as a marker of poor prognosis: benefit of oral anticoagulants. J Am Coll Cardiol 1999;33:1317–1322.
 
17. Special report from the National Institute of Neurological Disorders and Stroke: classification of cerebrovascular diseases III. Stroke 1990;21:637–676.
 
18. Hanley PC, Tajik AJ, Hynes JK, et al. Diagnosis and classification of atrial septal aneurysm by two-dimensional echocardiography: report of 80 consecutive cases. J Am Coll Cardiol 1985;6:1370–1382.
 
19. Marshall AC, Lock JE. Structural and compliant anatomy of the patent foramen ovale in patients undergoing transcatheter closure. Am Heart J 2000;140:303–307.
 
20. Tunick PA, Kronzon I. Embolism from the aorta: atheroemboli and thromboemboli. Curr Treat Options Cardiovasc Med 2001;3:181–186.
 
21. Dressler FA, Craig WR, Castello R, et al. Mobile aortic atheroma and systemic emboli: efficacy of anticoagulation and influence of plaque morphology on recurrent stroke. J Am Coll Cardiol 1998;31:134–138.
 
22. Paemelaere JM, Sirinelli A, Dreyfus X, et al. Transesophageal echography and systemic ischemic incidences: 235 cases. Rev Neurol 1996;152:27–31.
 
23. Chant H, McCollum C. Stroke in young adults: the role of paradoxical embolism. Thromb Haemost2001;85:22–29.
 
24. Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000;55:1172–1179.
 
25. Autore C, Cartoni D, Piccininno M: Multiplane transesophageal echocardiography and stroke. Am J Cardiol 1998;81:79G–81G
 
26. Jaber WA, Prior DL, Thamilarasan M, et al. Efficacy of anticoagulation in resolving left atrial and atrial appendage thrombi: a transesophageal echocardiographic study. Am Heart J 2000;140:150–156.
 
27. Sun SS, Hsieh JF, Tsai SC, et al. Monitoring the effect of anticoagulations on left atrial thrombi in patients with rheumatic heart disease: assessment with 111 In-oxide-labelled platelet heart scintigraphy and transesophageal echocardiography. Nucl Med Commun 2000;21:627–30.
 
28. Labeque JN, Laffort P, Lafiitte S, et al. Treatment of left atrial thrombosis by low-molecular-weight heparin: a preliminary study of 6 cases. Arch Mal Coeur Vaiss 2000;93:1528–1533.
 
29. Koenig P, Cao QL, Heitschmidt M, et al. Role of intracardiac echocardiographic guidance in transcatheter closure of atrial septal defects and patient foramen ovale using the Amplatzer device. J Interv Cardiol 2003;16:51–62.
 
30. Onorato E, Melzi G, Casilli R, et al. Patent foramen ovale with paradoxical embolism: mid-term results of transcatheter closure in 256 patients. J Interv Cardiol 2003;16:43–50.
 
31. Bialkowski J, Kusa J, Szkttnik M, et al. Percutaneous catheter closure of atrial septal defect: short-term and mid-term results. Rev Esp Cardiol 2003;56:383–388.
 
32. Herrara CJ, Frazin LJ, Dau PC, et al. Atherosclerotic plaque evolution in the descending thoracic aorta in familial hypercholesterolemic patients: a transesophageal echo study. Arterioscler Thromb1994;14:1723–1729.
 
33. Corti R, Fuster V, Fayad ZA, et al. Lipid lowering by simvastatin induces regression of human atherosclerotic lesions: two years' follow-up by high-resolution noninvasive magnetic resonance imaging.Circulation 2002;106:2884–2887.