title: Therapeutic strategies after examination by transesophageal echocardiography in 503 patients with ischemic stroke.
abstract: OBJECTIVE
  Transesophageal echocardiography (TEE) is the gold standard in detecting high-risk (ie, aortic thrombi) and potential sources (ie, patent foramen ovale [PFO]) of cerebral embolism. We sought to evaluate the additional information and therapeutic impact provided by TEE in stroke patients and to characterize patients in whom TEE is indispensable.
  
  
  METHODS
  We included 503 consecutive patients (mean age 62.2 years) with acute brain ischemia. Each patient received TEE and the following routine diagnostics: ultrasound of brain supplying arteries, ECG or Holter-ECG, transthoracic echocardiography, and brain imaging (computed tomography or MRI). Stroke etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. High-risk sources in TEE were: aortic thrombi or plaques > or =4 mm, thrombi in left atrial cavity/left atrial appendage, spontaneous echo contrast, and left atrial flow velocity <30 cm/s. Potential sources in TEE were PFO, atrial septal aneurysm, and aortic plaques <4 mm.
  
  
  RESULTS
  Stroke etiology was determined by routine diagnostics in 276 of 503 patients (54.9%). Of the remaining 227 patients (undetermined etiology), 212 (93.4%) were candidates for oral anticoagulation (OA). TEE revealed a high-risk source, with indication for OA in 17 of them (8.0%). A potential source leading to OA was found in an additional 48 patients (22.6%). The remaining 147 patients (69.3%) were treated by platelet inhibitors or statins.
  
  
  CONCLUSIONS
  TEE strongly influenced secondary prevention and led to OA in one third of our patients with stroke of undetermined etiology. TEE is indispensable in all patients being candidates for OA when routine diagnostics cannot clarify stroke etiology.
authors.affiliation: Department of Neurology and Clinical Neurophysiology, Albert-Ludwigs-Universität Freiburg, Germany. harloff@nz.ukl.uni-freiburg.de
authors.forename: Andreas
authors.initials: A
authors.lastname: Harloff
authors.forename: Michael
authors.initials: M
authors.lastname: Handke
authors.forename: Matthias
authors.initials: M
authors.lastname: Reinhard
authors.forename: Annette
authors.initials: A
authors.lastname: Geibel
authors.forename: Andreas
authors.initials: A
authors.lastname: Hetzel
mesh_terms: D000284:Administration, Oral; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000494:pharmacology; D001011:Aorta / Q000473:pathology; D001921:Brain / Q000473:pathology; D002561:Cerebrovascular Disorders / Q000175:diagnosis / Q000473:pathology; D004452:Echocardiography / Q000379:methods; D017548:Echocardiography, Transesophageal / Q000379:methods*; D006801:Humans; D020766:Intracranial Embolism / Q000473:pathology; D007511:Ischemia / Q000473:pathology* / Q000628:therapy*; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D015233:Models, Statistical; D012306:Risk; D020521:Stroke / Q000175:diagnosis / Q000473:pathology* / Q000628:therapy*; D013997:Time Factors
chemical_list: D000925:Anticoagulants