title: The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta-analysis.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: 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.
authors.forename: A H
authors.initials: AH
authors.lastname: Katsanos
authors.affiliation: Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece.
authors.forename: S
authors.initials: S
authors.lastname: Giannopoulos
authors.affiliation: Second Department of Cardiology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
authors.forename: A
authors.initials: A
authors.lastname: Frogoudaki
authors.affiliation: Second Department of Cardiology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
authors.forename: A-R
authors.initials: AR
authors.lastname: Vrettou
authors.affiliation: Second Department of Cardiology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
authors.forename: I
authors.initials: I
authors.lastname: Ikonomidis
authors.affiliation: Second Department of Cardiology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
authors.forename: I
authors.initials: I
authors.lastname: Paraskevaidis
authors.affiliation: Second Department of Neurology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
authors.forename: C
authors.initials: C
authors.lastname: Zompola
authors.affiliation: Department of Neurology, Democritus University of Thrace, Alexandroupolis, Greece.
authors.forename: K
authors.initials: K
authors.lastname: Vadikolias
authors.affiliation: Second Department of Neurosurgery, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
authors.forename: E
authors.initials: E
authors.lastname: Boviatsis
authors.affiliation: Second Department of Cardiology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
authors.forename: J
authors.initials: J
authors.lastname: Parissis
authors.affiliation: Second Department of Neurology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.
authors.forename: K
authors.initials: K
authors.lastname: Voumvourakis
authors.affiliation: Department of Neurology, School of Medicine, University of Ioannina, Ioannina, Greece.
authors.forename: A P
authors.initials: AP
authors.lastname: Kyritsis
authors.affiliation: 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.
authors.forename: G
authors.initials: G
authors.lastname: Tsivgoulis
mesh_terms: D002545:Brain Ischemia / Q000209:etiology*; D017548:Echocardiography, Transesophageal / Q000706:statistics & numerical data*; D005260:Female; D006331:Heart Diseases / Q000150:complications / Q000175:diagnosis*; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology; D008297:Male; D008875:Middle Aged; D020521:Stroke / Q000209:etiology*
keywords: cryptogenic; stroke; transesophageal echocardiography; transient ischaemic attack