Background&Purpose: The currently proposed criteria for the definition of embolic strokes of undetermined source (ESUS) do not include investigation with transesophageal echocardiography (TEE) among the mandatory diagnostic work-up. We sought to evaluate the diagnostic yield of TEE in consecutive patients fulfilling ESUS criteria.
Methods: We prospectively evaluated ischemic stroke (IS) patients fulfilling ESUS criteria from three tertiary care stroke centers during a twelve month period. All patients underwent additional diagnostic work-up with TEE to estimate both the diagnostic yield and the impact of TEE findings in the therapeutic management of patients with ESUS.
Results: We identified 61 patients with ESUS who underwent investigation with TEE [mean age 44.3±11.5 years; 49.2% males; median NIHSS=5 (IQR, 3-8)]. TEE revealed additional findings in 52.4% (95%CI by the adjusted Wald method: 40.2%-64.5%) of the patients. Patent foramen ovale (PFO) and atrial septal aneurysm (ASA) were reported in 27.8% (95%CI: 18.1%-40.2%) and 13.1% (95%CI: 6.5%-24.1%) of the study population respectively. The concurrence of PFO and ASA was reported in 4 patients (6.5%, 95%CI: 2.1%-16.1%). The presence of valvular vegetations was documented in 2 patients (3.2%; 95%CI: 0%-11.8%), while thrombus was found in the left atrium of one patient (1.6%, 95%CI: 0%-9.5%). Complex aortic arch atheromatosis was reported in 6.5% (95%CI: 2.1%-16.1%) of the patients. Neither myxomas, nor ventricular septal defects were found in TEE examinations. TEE findings changed the management in 16.4% (95%CI: 8.9%-27.8%) of the patients. Anticoagulants were initiated in 5 patients, while the other 2 patients with endocarditis received treatment with intravenous antibiotics. Finally, 3 of the 61 patients underwent a PFO-closure procedure due to the large size of the shunt and the previous history of recurrent cryptogenic IS.
Conclusions: Our findings suggest that ESUS patients should undergo investigation with TEE in search of potential cardioembolic or aortogenic sources. TEE findings may have a decisive impact on the selection of the appropriate therapeutic approach for these patients.