Transesophageal echocardiography (TEE) vs. transthoracic echocardiography (TTE) in assessing cardio-vascular sources of emboli in patients with acute ischemic stroke.

BACKGROUND: Transesophageal echocardiography (TEE) is a valuable tool in the evaluation of ischemic stroke patients. However, the real clinical impact of additional TEE data remains to be defined. Our purpose was to evaluate the impact of TEE on the management of patients at low risk for cardiogenic embolism.

MATERIAL/METHODS: We studied 68 patients (57+/-10 years old) with ischemic stroke at low-risk for cardiogenic embolism. Each patient underwent bilateral carotid ultrasound Doppler study, trans-thoracic echocardiography (TTE) and TEE in order to find out left atrial spontaneous echo contrast or intracavitary thrombi, communication or aneurysm of the inter-atrial septum, ventricular septal defect, patent foramen ovale, and the presence of intra-aortic atherosclerotic plaques or thrombi.

RESULTS: In 28 out of 68 patients TEE found an abnormal lesion that has not been detected by TTE: there were 23 diffuse (>5mm) atherosclerotic atheromas in the aortic arch, 5 patent foramen ovale (PFO) lesions, 3 left atrial thrombi, 1 ventricular septal defect (VSD), and 1 atrial septal defect (ASD). 6 patients had more than 1 finding. These findings changed the management, and all 28 patients started to be treated with Coumadine instead of Aspirin. Patients with PFO were sent to close the shunt with a patch.

CONCLUSIONS: In half of the patients TEE (but not TTE) found a significant lesion that changed our policy of management. None of these lesions were detected by TTE. It seems that TEE is mandatory in the evaluation of patients with acute ischemic stroke.