Skip to main content
NCBI home page
Clinical Cardiology logoLink to Clinical Cardiology
. 2009 Feb 3;22(6):391–396. doi: 10.1002/clc.4960220605

Transesophageal echocardiography for the evaluation and management of patients with cerebral ischemia

Amin F Rahmatullah 1, Peter S Rahko 1, James H Stein 1,✉
PMCID: PMC6655765  PMID: 10376177

Abstract

To prevent recurrent strokes and transient ischemic attacks, considerable attention is devoted to investigating the etiology of acute cerebral ischemia in the large subpopulation of patients without an easily identifiable cause. In general, transthoracic echocardiography is an insensitive tool for the evaluation of patients with cerebral ischemia, unless clinical signs and/or symptoms of cardiac disease are present. Transesophageal echocardiography (TEE), because of its increased sensitivity for aortic arch atheromata, atrial septal pathology, left atrial thrombi, and valvular abnormalities, is the preferred cardiac imaging modality, especially in young patients, older patients with hypertension or systemic atherosclerosis, and patients with prosthetic heart valves. This paper reviews the prognostic and therapeutic impact of TEE in patients with cerebral ischemia, specifically focusing on the ability of information obtained by this technique to alter patient management and improve risk stratification.

Keywords: echocardiography, stroke, transesophageal echocardiography

Full Text

The Full Text of this article is available as a PDF (874.9 KB).

References

  • 1. Dressler FA, Labovitz AJ: Systemic arterial emboli and cardiac masses: Assessment with transesophageal echocardiography. Cardiol Clin: Transesophageal Echocardiography 1993; 11: 447–460 [PubMed] [Google Scholar]
  • 2. Feinberg WM, Albers GW, Barnett HJM, Biller J, Caplan LR, Carter LP, Hart RG, Hobson RW II, Kronmal RA, Moore WS, Robertson JT, Adams HP Jr, Mayberg M: Guidelines for the management of transient ischemic attacks. Circulation 1994; 89: 2950–2965 [DOI] [PubMed] [Google Scholar]
  • 3. Pearson AC, Labovitz AJ, Tatineni S, Gomez CR: Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. J Am Coll Cardiol 1991; 17: 66–72 [DOI] [PubMed] [Google Scholar]
  • 4. Lovett JL, Sandok BA, Giuliani ER, Nasser FN: Two‐dimensional echocardiography in patients with focal cerebral ischemia. Ann Intern Med 1981; 95: 1–4 [DOI] [PubMed] [Google Scholar]
  • 5. Sansoy V, Abbott RD, Jayaweera AR, Kaul S: Low yield of transthoracic echocardiography for cardiac source of embolism. Am J Cardiol 1995; 75: 166–169 [DOI] [PubMed] [Google Scholar]
  • 6. Biller J, Johnson MR, Adams HP, Kerber RE, Toffol GJ, Butler MJ: Echocardiographic evaluation of young adults with nonhemorrhagic cerebral infarction. Stroke 1986; 17: 608–612 [DOI] [PubMed] [Google Scholar]
  • 7. Souquet J, Hanrath P, Zitelli L: Transesophageal phased array for imaging of the heart. IEEE Trans Biomed Eng 1982; 29: 707–712 [DOI] [PubMed] [Google Scholar]
  • 8. Lee RJ, Bartzokis T, Yeoh T‐K, Grogin HR, Choi D, Schnittger I: Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography. Stroke 1991; 22: 734–739 [DOI] [PubMed] [Google Scholar]
  • 9. Labovitz AJ, Pearson AL: Transesophageal Echocardiography: Basic Principles and Clinical Applications. Philadelphia: Lea and Febiger, 1993. [Google Scholar]
  • 10. Leung DY, Black IW, Cranney GB, Walsh WF, Grimm RA, Stewart WJ, Thomas JD: Selection of patients for transesophageal echocardiography after stroke and systemic embolic events: Role of transthoracic echocardiography. Stroke 1995; 26: 1820–1824 [DOI] [PubMed] [Google Scholar]
  • 11. O'Brien PJ, Thiemann DR, McNamara RL, Roberts JW, Raska K, Oppenheimer SM, Lima JAC: Usefulness of transesophageal echocardiography in predicting mortality and morbidity in stroke patients without clinically known cardiac sources of embolus. Am J Cardiol 1998; 81: 1144–1151 [DOI] [PubMed] [Google Scholar]
  • 12. Stollberger C, Brainin M, Abzieher F, Slany J: Embolic stroke and transesophageal echocardiography: Can clinical parameters predict the diagnostic yield? J Neurol 1995; 242: 437–442 [DOI] [PubMed] [Google Scholar]
  • 13. Daniel WG, Nellessen U, Schroeder E, Nonmast‐Daniel B, Bednarski P, Nikulta P, Lichtlen PR: Left atrial spontaneous echo contrast in mitral valve disease. An indicator for an increased thromboembolic risk. J Am Coll Cardiol 1988; 11: 1204–1211 [DOI] [PubMed] [Google Scholar]
  • 14. Stratton JR, Lighty GW, Pearlman AS, Ritchie JL: Detection of left ventricular thrombus by two‐dimensional echocardiography. Sensitivity, specificity and causes of uncertainty. Circulation 1982; 66: 156–166 [DOI] [PubMed] [Google Scholar]
  • 15. Lechat PH, Mas JL, Lascault G, Loron PH, Theard M, Klimczac M, Drobinski G, Thomas D, Grosgogeat Y: Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988; 318: 1148–1152 [DOI] [PubMed] [Google Scholar]
  • 16. Webster MWJ, Chancellor AM, Smith HJ, Swift DL, Sharpe DN, Bass NM, Glasgow GL: Patent foramen ovale in young stroke patients. Lancet 1988; 2: 11–12 [DOI] [PubMed] [Google Scholar]
  • 17. De Belder MA, Tovrikis K, Leech G, Camm AJ: Risk of patent foramen ovale for thromboembolic events in all age groups. Am J Cardiol 1992; 69: 1316–1320 [DOI] [PubMed] [Google Scholar]
  • 18. Hausmann D, Mügge A, Becht I, Daniel WG: Diagnosis of patent foramen ovale by transesophageal echocardiography and association with cerebral and peripheral embolic events. Am J Cardiol 1992; 70: 668–672 [DOI] [PubMed] [Google Scholar]
  • 19. Hanley P, Tajik AJ, Hynes JK, Edwards WP, Reeder GS, Hagler DJ, Seward JB: Diagnosis and classification of atrial septal aneurysm by two‐dimensional echocardiography: Report of 80 consecutive cases. J Am Coll Cardiol 1985; 6: 1370–1382 [DOI] [PubMed] [Google Scholar]
  • 20. Mugge A, Daniel WG, Angermann C, Spes C, Khandheria BK, Kronzon I, Freedberg RS, Keren A, Dennig K, Engberding R, Sutherland GR, Vered Z, Erbel R, Visser CA, Lindert O, Hausmann D, Wenzlaff P: Atrial septal aneurysm in adult patients: A multi‐center study using transthoracic and transesophageal echocardiography. Circulation 1995; 91: 2785–2792 [DOI] [PubMed] [Google Scholar]
  • 21. Helwig FC: The frequency of anomalous reticula in the right atrium of the human heart—“Chiari Network”: Report of eight cases. Am J Pathol 1932. 8: 73–79 [PMC free article] [PubMed] [Google Scholar]
  • 22. Gresham GA: Networks in the right side of the heart. Br Heart J 1957; 19: 381–386 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23. Pop G, Sutherland GR, Koudstaal PJ, Sit TW, de Jong G, Roelandt JRTC: Transesophageal echocardiography in the detection of intracardiac embolic sources in patients with transient ischemic attacks. Stroke 1990; 21: 560–565 [DOI] [PubMed] [Google Scholar]
  • 24. Karalis DG, Chandrasekaran K, Victor MF, Ross JJ, Mintz GS: Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol 1991; 17: 73–78 [DOI] [PubMed] [Google Scholar]
  • 25. Tunick PA, Perez JL, Kronzon I: Protruding atheromas in the thoracic aorta and systemic embolization. Ann Intern Med 1991; 115: 423–427 [DOI] [PubMed] [Google Scholar]
  • 26. Savage DD, Garrison RJ, Castelli WP, McNamara PM, Anderson SJ, Kannel WB, Feinleib M: Prevalence of submitral (annular) calcium and its correlates in a general population based sample (The Framingham Study). Am J Cardiol 1983; 51: 1375–1398 [DOI] [PubMed] [Google Scholar]
  • 27. Benjamin EJ, Plehn JF, D'Agostino RB, Belanger AJ, Comai K, Fuller DL, Wolf PA, Levy D: Mitral annular calcification and the risk of stroke in an elderly cohort. N Engl J Med 1992; 327: 374–379 [DOI] [PubMed] [Google Scholar]
  • 28. Stein JH, Soble JS: Thrombus associated with mitral valve calcification: A possible mechanism for embolic stroke. Stroke 1995; 26: 1697–1699 [DOI] [PubMed] [Google Scholar]
  • 29. Cerebral Embolism Task Force : Cardiogenic brain embolism: The second report of the Cerebral Embolism Task Force. Arch Neurol 1989; 46: 727–743 [PubMed] [Google Scholar]
  • 30. Orsinelli DA, Pearson AC: Detection of prosthetic valve strands by transesophageal echocardiography: Clinical significance in patients with suspected cardiac source of embolism. J Am Coll Cardiol 1995; 26: 1713–1718 [DOI] [PubMed] [Google Scholar]
  • 31. Freedberg RS, Goodkin GM, Perez JL, Tunick PA, Kronzon I: Valve strands are strongly associated with systemic embolization: A transesophageal echocardiography study. J Am Coll Cardiol 1995; 26: 1709–1712 [DOI] [PubMed] [Google Scholar]
  • 32. Stein JH, Marcus RM: Transesophageal echocardiography and cerebral ischemic events (letter). Arch Intern Med 1997; 157: 760–761 [Google Scholar]
  • 33. Dressler FA, Craig WR, Costello D, Lakovitz AJ: Mobile aortic atheroma and systemic emboli: Efficacy of anticoagulation and evidence of plaque morphology on recent stroke. J Am Coll Cardiol 1998; 31: 134–138 [DOI] [PubMed] [Google Scholar]
  • 34. Montgomery DH, Ververis JJ, McGorisk G, Frohwein S, Martin RP, Taylor WR: Natural history of severe atheromatous disease of the thoracic aorta: A transesophageal echocardiographic study. J Am Coll Cardiol 1996; 27: 95–101 [DOI] [PubMed] [Google Scholar]
  • 35. Dee W, Geibel A, Kasper W, Konstantinides S, Just H: Mobile thrombi in atherosclerotic lesions of the thoracic aorta: The diagnostic impact of transesophageal echocardiography. Am Heart J 1993; 126: 707–710 [DOI] [PubMed] [Google Scholar]
  • 36. Spes CH, Mügge A, Daniel WG, Tammen AR, Kühn H, Theisen K, Angermann CE: Follow‐up of embolic events in patients after diagnosis of atrial septal aneurysm (abstr). J Am Coll Cardiol 1996; 27: 161A 8522691 [Google Scholar]
  • 37. Crouse JR, Byington RP, Hoen HM, Furberg CD: Reductase inhibitor monotherapy and stroke prevention. Arch Intern Med 1997; 157: 1305–1310 [PubMed] [Google Scholar]
  • 38. Bucher HC, Griffith LE, Guyatt GH: Effect of HMGcoA reductase inhibitors on stroke. A meta‐analysis of randomized controlled trials. Ann Intern Med 1998; 128: 89–95 [DOI] [PubMed] [Google Scholar]
  • 39. Pitsavos CE, Barbetseas JD, Skoumas JN, Aggeli CI, Lambrou SG, Frogoudaki AA, Stefanadis CI, Toutouzas PK: Evolution of thoracic aorta atherosclerosis in patients with heterozygous familial hypercholesterolemia after statin therapy (abstr). J Am Coll Cardiol 1998; 31: 281A [DOI] [PubMed] [Google Scholar]
  • 40. Stöllberger C, Slany J, Schuster I, Leitner H, Winkler W‐B, Karnik R: The prevalence of deep venous thrombosis in patients with suspected paradoxical embolism. Ann Intern Med 1993; 119: 461–465 [DOI] [PubMed] [Google Scholar]
  • 41. Lethen H, Beck F, Köhn G, Schneider R, Sliwka U, Franke A, Flachskampf FA, Noth J, Hanrath P: Role of patent foramen ovale and deep venous thrombosis in 220 patients with unexplained stroke or transient ischemic attack: A prospective transthoracic and transesophageal echocardiographic study (abstr). J Am Coll Cardiol 1995; 25: 145A [Google Scholar]
  • 42. Dearani JA, Morris JJ, Click RL, Petty GW, Bailey KR, Khandheria BK: PFO closure to prevent recurrent stroke or TIA in young adults (abstr). J Am Coll Cardiol 1996; 27: 709A [Google Scholar]
  • 43. Ende DJ, Chopra PS, Rao PS: Transcatheter closure of atrial septal defect or patent foramen ovale with the buttoned device for prevention of recurrence of paradoxic embolism. Am J Cardiol 1996; 78: 233–236 [PubMed] [Google Scholar]
  • 44. Job FP, Ringelstein EB, Grafen Y, Flachskampf FA, Doherty C, Stockmanns A, Hanrath P: Comparison of transcranial contrast Doppler sonography and transesophageal contrast echocardiography for the detection of patent foramen ovale in young stroke patients. Am J Cardiol 1994; 74: 381–384 [DOI] [PubMed] [Google Scholar]
  • 45. Klotzsch C, Janssen G, Berlit P: Transesophageal echocardiography and contrast‐TCD in the detection of a patent foramen ovale: Experiences with 111 patients. Neurology 1994; 44: 1603–1606 [DOI] [PubMed] [Google Scholar]
  • 46. Hausmann D, Mügge A, Daniel WG: Identification of patent foramen ovale permitting paradoxic embolism. J Am Coll Cardiol 1995; 26: 1030–1038 [DOI] [PubMed] [Google Scholar]
  • 47. De Castro S, Cartoni D, Rasura M, Beni S, Anzini A, Moschini Antinori M, Pelliccia F, Giannantoni P: Characteristics of patent foramen ovale in stroke patients: Two‐dimensional and biplane contrast transesophageal study (abstr). J Am Coll Cardiol 1995; 25: 145A [Google Scholar]
  • 48. De Castro S, Cartoni D, Fiorelli M, Rasura M, Anzini A, Beni S, Magni G, Fedele F, Pandian N: Right‐to‐left shunt at rest and increased mobility of atrial septum identify a subgroup of PFO patients at higher risk for recurrent embolism (abstr). J Am Coll Cardiol 1996; 27: 161A 8522691 [Google Scholar]
  • 49. Stone DA, Godard J, Corretti MC, Kittner SJ, Sample C, Price TR, Plotnick GD: Patent foramen ovale: Association between the degree of shunt by contrast transesophageal echocardiography and the risk of future ischemic neurologic events. Am Heart J 1996; 131: 158–161 [DOI] [PubMed] [Google Scholar]
  • 50. The French Study of Aortic Plaques in Stroke Group : Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med 1996; 334: 1216–1221 [DOI] [PubMed] [Google Scholar]
  • 51. Kronzon I, Tunick PA: Atheromatous disease of the thoracic aorta: Pathologic and clinical implications. Ann Intern Med 1997; 126: 629–637 [DOI] [PubMed] [Google Scholar]
  • 52. McNamara RL, Lima JAC, Whelton PK, Powe NR: Echocardiographic identification of cardiovascular sources of emboli to guide clinical management of stroke: A cost‐effectiveness analysis. Ann Intern Med 1997; 127: 775–787 [DOI] [PubMed] [Google Scholar]
  • 53. Little RW, Otero CL, Berger AK, Yohe MA, Chase G, Gersh BJ, Weissman NJ: Which patients should undergo TEE after a stroke (abstr). J Am Soc Echocardiogr 1997; 10: 394 [Google Scholar]

Articles from Clinical Cardiology are provided here courtesy of Wiley

RESOURCES