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The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta-analysis

AH. Katsanos, S. Giannopoulos, A. Frogoudaki, AR. Vrettou, I. Ikonomidis, I. Paraskevaidis, C. Zompola, K. Vadikolias, E. Boviatsis, J. Parissis, K. Voumvourakis, AP. Kyritsis, G. Tsivgoulis,

. 2016 ; 23 (3) : 569-79. [pub] 20151119

Language English Country England, Great Britain

Document type Journal Article, Meta-Analysis, Research Support, Non-U.S. Gov't, Review

Persistent link   https://www.medvik.cz/link/bmc17000403

BACKGROUND AND PURPOSE: The diagnostic utility of transesophageal echocardiography (TEE) in patients with cryptogenic ischaemic stroke (IS) or transient ischaemic attack (TIA) remains controversial. METHODS: A systematic review and meta-analysis was performed according to PRISMA guidelines to estimate the pooled prevalence of potential cardioembolic causes detected by TEE in prospective observational studies of cryptogenic IS/TIA. Cardiac conditions causally associated with cerebral ischaemia were considered to be intramural thrombi and intracardiac tumors according to ASCO phenotyping of IS. RESULTS: Thirty-five eligible studies, comprising 5772 patients (mean age 53.6 years, 56.9% men) were identified. The most common TEE finding was ascending aorta and/or aortic arch atheroma [51.2% (27.4%-74.5%)], followed by patent foramen ovale (PFO) [43.2% (36.3%-50.4%)]. Complex aortic plaques and large PFOs were reported in 14% (10.2%-18.9%) and 19.5% (16.6%-22.8%) of TEE evaluations. The prevalence of atrial septal aneurysm was 12.3% (7.9%-18.7%) and was significantly higher in conjunction with PFO presence (risk ratio 2.04, 95% confidence interval 1.63-2.54, P < 0.001). The prevalence of left atrial thrombus [3.0% (1.1%-8.3%)] and spontaneous echo contrast [3.8% (2.3%-6.2%)] was low. The prevalence of intracardiac tumors was extremely uncommon [0.2% (0%-0.7%)]. Significant heterogeneity was identified (I(2) > 60%) in the majority of analyses. Heterogeneity was not affected by cryptogenic stroke definition (TOAST versus alternative criteria). After dichotomizing available studies using a cut-off of 50 years, PFO was significantly (P = 0.001) more prevalent in younger than in older patients. CONCLUSION: Routine TEE in patients with cryptogenic IS/TIA commonly identifies abnormal findings. However, the prevalence of cardiac conditions considered to be causally associated with cerebral ischaemia (intracardiac thrombi and tumors) is low.

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$a Katsanos, A H $u Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece. Second Department of Neurology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
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$a The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta-analysis / $c AH. Katsanos, S. Giannopoulos, A. Frogoudaki, AR. Vrettou, I. Ikonomidis, I. Paraskevaidis, C. Zompola, K. Vadikolias, E. Boviatsis, J. Parissis, K. Voumvourakis, AP. Kyritsis, G. Tsivgoulis,
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$a BACKGROUND AND PURPOSE: The diagnostic utility of transesophageal echocardiography (TEE) in patients with cryptogenic ischaemic stroke (IS) or transient ischaemic attack (TIA) remains controversial. METHODS: A systematic review and meta-analysis was performed according to PRISMA guidelines to estimate the pooled prevalence of potential cardioembolic causes detected by TEE in prospective observational studies of cryptogenic IS/TIA. Cardiac conditions causally associated with cerebral ischaemia were considered to be intramural thrombi and intracardiac tumors according to ASCO phenotyping of IS. RESULTS: Thirty-five eligible studies, comprising 5772 patients (mean age 53.6 years, 56.9% men) were identified. The most common TEE finding was ascending aorta and/or aortic arch atheroma [51.2% (27.4%-74.5%)], followed by patent foramen ovale (PFO) [43.2% (36.3%-50.4%)]. Complex aortic plaques and large PFOs were reported in 14% (10.2%-18.9%) and 19.5% (16.6%-22.8%) of TEE evaluations. The prevalence of atrial septal aneurysm was 12.3% (7.9%-18.7%) and was significantly higher in conjunction with PFO presence (risk ratio 2.04, 95% confidence interval 1.63-2.54, P < 0.001). The prevalence of left atrial thrombus [3.0% (1.1%-8.3%)] and spontaneous echo contrast [3.8% (2.3%-6.2%)] was low. The prevalence of intracardiac tumors was extremely uncommon [0.2% (0%-0.7%)]. Significant heterogeneity was identified (I(2) > 60%) in the majority of analyses. Heterogeneity was not affected by cryptogenic stroke definition (TOAST versus alternative criteria). After dichotomizing available studies using a cut-off of 50 years, PFO was significantly (P = 0.001) more prevalent in younger than in older patients. CONCLUSION: Routine TEE in patients with cryptogenic IS/TIA commonly identifies abnormal findings. However, the prevalence of cardiac conditions considered to be causally associated with cerebral ischaemia (intracardiac thrombi and tumors) is low.
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$a Giannopoulos, S $u Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece.
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$a Frogoudaki, A $u Second Department of Cardiology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
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$a Boviatsis, E $u Second Department of Neurosurgery, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
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$a Kyritsis, A P $u Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece.
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$a Tsivgoulis, G $u Second Department of Neurology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece. Department of Neurology, Democritus University of Thrace, Alexandroupolis, Greece. International Clinical Research Center, Department of Neurology, St Anne's University Hospital, Brno, Czech Republic.
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