European Stroke Organisation (ESO) Guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke

Patent foramen ovale (PFO) is frequently identified in young patients with cryptogenic ischaemic stroke. Potential stroke mechanisms include paradoxical embolism from a venous clot which traverses the PFO, in situ clot formation within the PFO, and atrial arrhythmias due to electrical signalling disruption. The purpose of this guideline is to provide recommendations for diagnosing, treating, and long-term managing patients with ischaemic stroke and PFO. Conversely, Transient Ischaemic Attack (TIA) was not considered an index event in this context because only one RCT involved TIA patients. However, this subgroup analysis showed no significant differences between TIA and stroke outcomes. The working group identified questions and outcomes, graded evidence, and developed recommendations following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and the European Stroke Organisation (ESO) standard operating procedure for guideline development. This document underwent peer-review by independent experts and members of the ESO Guideline Board and Executive Committee. The working group acknowledges the current evidentiary gap in delineating an unequivocal diagnostic algorithm for the detection of PFO. Although transoesophageal echocardiography is conventionally held as the most accurate diagnostic tool for PFO identification, its status as the 'gold standard' remains unsubstantiated by rigorously validated evidence. We found high-quality evidence to recommend PFO closure plus antiplatelet therapy in selected patients aged 18-60 years in whom no other evident cause of stroke is found but a PFO (i.e. PFO-associated stroke). The PASCAL classification system can be used to select such candidates for PFO closure. Patients with both a large right-to-left shunt and an atrial septal aneurysm benefit most from PFO closure. There is insufficient evidence to make an evidence-based recommendation on PFO closure in patients older than 60 and younger than 18 years. We found low quality evidence to suggest against PFO closure in patients with unlikely PFO-related stroke according to the PASCAL classification, except in specific scenarios (Expert Consensus). We suggest against long-term anticoagulation in patients with PFO-associated stroke unless anticoagulation is indicated for other medical reasons. Regarding the long-term AF monitoring after PFO closure, the working group concluded that there remains significant uncertainty regarding the risks and benefits associated with the use of long-term cardiac monitoring, such as implantable loop recorders. This document provides additional guidance, in the form of evidence-based recommendations or expert consensus statements, on diagnostic methods for PFO detection, and medical management after PFO closure.

Overview and Future Direction of Embolic Stroke of Undetermined Source from the Insights of CHALLENGE ESUS/CS Registry

Cryptogenic stroke (CS) accounts for approximately one-fourth of acute ischemic strokes, with most cases derived from embolic etiologies. In 2014, embolic stroke of undetermined source (ESUS) was advocated and the efficacy of anticoagulant therapy was anticipated. However, 3 large-scale clinical trials failed to demonstrate the superiority of direct oral anticoagulants (DOACs) over aspirin, potentially due to the heterogeneous and diverse pathologies of ESUS, including paroxysmal atrial fibrillation (AF), arteriogenic sources such as nonstenotic carotid plaque and aortic complicated lesion (ACL), patent foramen oval (PFO), and nonbacterial thrombotic endocarditis (NBTE) related to active cancer.Transesophageal echocardiography (TEE) is one of the most effective imaging modalities for assessing embolic sources in ESUS and CS. The Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for Embolic Stroke of Undetermined Source/Cryptogenic Stroke (CHALLENGE ESUS/CS) registry is a multicenter registry that enrolled consecutive patients with CS who underwent TEE at 8 hospitals in Japan between April 2014 and December 2016. Their mean age was 68.7±12.8 years, and 455 patients (67.2%) were male. The median National Institutes of Health Stroke Scale (NIHSS) score was 2. Since 7 analyses have been conducted from each institution to date, novel and significant insights regarding embolic origins and pathophysiologies of ESUS and CS were elucidated from this multicenter registry. This review discusses the diagnosis and treatment of ESUS and CS, tracing their past and future directions. Meaningful insights from the CHALLENGE ESUS/CS registry are also referenced and analyzed.

Right to Left Shunt and Cryptogenic Stroke in Patients Over 60 Years Old

OBJECTIVE

To determine the possible role of patent foramen ovale (PFO) as indicated by a right to left shunt and cryptogenic stroke in patients aged ≥ 60 years and to compare the prevalence of patent foramen ovale with stroke of known cause.

METHODS

We prospectively examined the prevalence of PFO using contrast enhanced colour Transcranial Doppler ultrasonography (bubble-cTCD) in 86 consecutive patients aged ≥60 years with transient ischaemic attack (TIA) or stroke and 86 consecutive patients aged <60 years with TIA/stroke as a control group. Patients with cryptogenic stroke were compared to stroke patients with known cause.

RESULTS

A significantly higher prevalence of PFO in patients with cryptogenic compared to patients with stroke of known cause was registered in the patients aged < 60 years (56.6% vs.18.8%) and in patients aged ≥ 60 years (37.14% vs.11.76%), respectively. Multivariate analysis adjusted for age, hypertension and coronary disease showed that the existence of R-to-L shunt (RLS) was independently associated with cryptogenic stroke in both, in the younger group (odds ratio 4.012; 95% CI1.323 to 12.171, p =0.0143.70) and in the older group (odds ratio 3.197; 95% CI 1.140 to 10.877, p=0.037).

CONCLUSION

Our findings suggest that PFO is strongly associated with cryptogenic stroke in patients aged ≥ 60 years. Bubble - cTCD was feasible and suitable as a first-line method for the detection of PFO in older patients.

Transesophageal echocardiography and computerized tomography angiography mismatch in left atrial appendage thrombus evaluation

BACKGROUND

Transesophageal echocardiography (TEE) is the gold standard test for the diagnosis of left atrial appendage (LAA) thrombus. Nonetheless, computerized tomography angiography (CTA) is readily used to exclude LAA thrombus before pulmonary vein isolation (PVI) and LAA closure procedures. We aimed to assess the comparability of LAA thrombus diagnosis using chest CTA scans in patients with atrial fibrillation who underwent TEE.

METHODS

Retrospective collection of consecutive patients with atrial fibrillation who underwent TEE and chest CTA within 30 days and had evidence of spontaneous echo contrast (SEC) or LAA thrombus on TEE. Clinical, demographic, and echo data were collected. Prospective analysis of the CTA for evidence of LAA thrombus in the same group of patients was performed. We compared the findings of the two modalities.

RESULTS

Out of 1550 patients with atrial fibrillation who underwent TEE examinations in the study period, 63 patients underwent TEE within 30 days of a chest CTA scan. Twenty-three patients had LAA thrombus and 40 had some degree of SEC according to TEE. On CTA, 11 were interpreted as positive with a high level of suspicion for the presence of an LAA thrombus. Six patients (26.1%) had LAA thrombus according to both CT and TEE. Therefore, low concordance was found between test results (chi-squared continuity correction = 5.5, df  = 1, and P -value = 0.01902).

CONCLUSION

The discrepancy between CTA and TEE results suggests these examinations might be more suitable as complementary examinations to exclude LAA thrombus.

Imaging Biomarkers and Prevalence of Complex Aortic Plaque in Cryptogenic Stroke: A Systematic Review

BACKGROUND

Complex aortic plaque (CAP) is a potential embolic source in patients with cryptogenic stroke (CS). We review CAP imaging criteria for transesophageal echocardiogram (TEE), computed tomography angiography (CTA), and magnetic resonance imaging and calculate CAP prevalence in patients with acute CS.

METHODS AND RESULTS

PubMed and EMBASE databases were searched up to December 2022 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Two independent reviewers extracted data on study design, imaging techniques, CAP criteria, and prevalence. The Cochrane Collaboration tool and Guideline for Reporting Reliability and Agreement Studies were used to assess risk of bias and reporting completeness, respectively. From 2293 studies, 45 were reviewed for CAP imaging biomarker criteria in patients with acute CS (N=37 TEE; N=9 CTA; N=6 magnetic resonance imaging). Most studies (74%) used ≥4 mm plaque thickness as the imaging criterion for CAP although ≥1 mm (N=1, CTA), ≥5 mm (N=5, TEE), and ≥6 mm (N=2, CTA) were also reported. Additional features included mobility, ulceration, thrombus, protrusions, and assessment of plaque composition. From 23 prospective studies, CAP was detected in 960 of 2778 patients with CS (0.32 [95% CI, 0.24-0.41], I2=94%). By modality, prevalence estimates were 0.29 (95% CI, 0.20-0.40; I2=95%) for TEE; 0.23 (95% CI, 0.15-0.34; I2=87%) for CTA and 0.22 (95% CI, 0.06-0.54; I2=92%) for magnetic resonance imaging.

CONCLUSIONS

TEE was commonly used to assess CAP in patients with CS. The most common CAP imaging biomarker was ≥4 mm plaque thickness. CAP was observed in one-third of patients with acute CS. However, high study heterogeneity suggests a need for reproducible imaging methods.

Regulated cell death joins in atherosclerotic plaque silent progression

Non-apoptotic regulated cell death (ferroptosis and necroptosis) leads to the release of damage-associated molecular patterns (DAMPs), which initiate and perpetuate a non-infectious inflammatory response. We hypothesize that DAMPs and non-apoptotic regulated cell death are critical players of atherosclerotic plaque progression with inadequate response to lipid-lowering treatment. We aimed to uncover the silent mechanisms that govern the existing residual risk of cardiovascular-related mortality in experimental atherosclerosis. Proteomic and genomic approaches were applied on the ascending aorta of hyperlipidemic rabbits and controls with and without lipid-lowering treatment. The hyperlipidemic animals, which presented numerous heterogeneous atherosclerotic lesions, exhibited high concentrations of serum lipids and increased lipid peroxidation oxidative stress markers. The analyses revealed the significant upregulation of DAMPs and proteins implicated in ferroptosis and necroptosis by hyperlipidemia. Some of them did not respond to lipid-lowering treatment. Dysregulation of five proteins involved in non-apoptotic regulated cell death proteins (VDAC1, VDAC3, FTL, TF and PCBP1) and nine associated DAMPs (HSP90AA1, HSP90AB1, ANXA1, LGALS3, HSP90B1, S100A11, FN, CALR, H3-3A) was not corrected by the treatment. These proteins could play a key role in the atherosclerotic silent evolution and may possess an unexplored therapeutic potential. Mass spectrometry data are available via ProteomeXchange with identifier PXD026379.

Advances in the management of cardioembolic stroke associated with patent foramen ovale

Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.

Diagnostic Yield of TEE in Patients with Cryptogenic Stroke and TIA with Normal TTE: A Systematic Review and Meta-Analysis

INTRODUCTION

The role of transesophageal echocardiography (TEE) in cryptogenic stroke and transient ischemic attack (TIA) with normal transthoracic echocardiography (TTE) remains controversial in the absence of definite guidelines. We aimed to perform a systematic review and meta-analysis to estimate an additional diagnostic yield and clinical impact of TEE in patients with cryptogenic stroke and TIA with normal TTE.

METHODS

We performed a systematic review of cohort studies on PubMed using the keywords 'cryptogenic stroke', cryptogenic TIA', 'TEE', and 'TTE' with matching MeSH terms. We included studies with patients who had cryptogenic stroke or TIA and had normal TTE findings, where the study intended to obtain TEE on all patients and reported all TEE abnormalities. The studies containing patients with atrial fibrillation were excluded. All studies were evaluated for internal and external validity. Inverse variance random effects models were used to calculate the effect size, the number needed to diagnose, and the 95% confidence interval.

RESULTS

We included 15 studies with 2054 patients and found LA/LAA/aortic thrombus, valvular vegetation, PFO-ASA, valvular abnormalities, and complex aortic plaques on TEE. Of these, 37.5% (29.7%-45.1%) of patients had additional cardiac findings on TEE. Management of 13.6% (8.1%-19.1%) of patients had changed after TEE evaluation. Based on current guidelines, it should change management in 4.1% (2.1%-6.2%) of patients and could potentially change management in 30.4% (21.9%-38.9%) of patients. Sensitivity analysis was also performed with only class II studies to increase internal validity, which showed additional cardiac findings in 38.4% (28.5%-48.3%), changed management in 20.2% (8.7%-31.8%), should change management in 4.7% (1.5%-7.9%), and could potentially change management in 30.4% (17.8%-43.0%) of patients.

CONCLUSIONS

The diagnostic yield of TEE to find any additional cardiac findings in patients with cryptogenic stroke or TIA is not only high, but it can also change management for certain cardiac abnormalities. TTE in cryptogenic stroke or TIA may mitigate future risks by tailoring the management of these patients.

EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography

Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.

Expert opinion paper on cardiac imaging after ischemic stroke

This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.

Cardiac imaging in ischemic stroke or transient ischemic attack of undetermined cause: Systematic review & meta-analysis

BACKGROUND

Patients with ischemic stroke or transient ischemic attack (TIA) of undetermined cause often undergo cardiac imaging in search of a cardioembolic source. As the choice of the most appropriate imaging approach is controversial and therapeutic implications have changed over time, we aimed to identify in patients with "cryptogenic stroke or TIA" the yield of transthoracic or transesophageal echocardiography (TTE or TEE) and cardiac computed tomography (CT).

METHODS AND RESULTS

We performed a systematic review and meta-analysis according to the PRISMA guidelines. Included were studies that assessed consecutive patients with ischemic stroke or TIA of undetermined cause to evaluate the yield of TTE, TEE, or cardiac CT for detecting cardioembolic sources. For each type of cardioembolic source the pooled prevalence was calculated. Only six out of 1458 studies fulfilled the inclusion criteria (1022 patients). One study reported the yield of TTE, four of TEE, and one of both TTE and TEE; no study assessed cardiac CT. Mean patient age ranged from 44.3-71.2 years, 49.2-59.7% were male. TTE detected 43 cardioembolic sources in 316 patients (4 (1.3%) major, 39 (12.3%) minor), and TEE 248 in 937 patients (55 (5.9%) major, 193 (20.6%) minor). The most prevalent major cardioembolic source was left atrial appendage thrombus, yet results were heterogeneous among studies.

CONCLUSIONS

TTE and TEE infrequently detect major cardioembolic sources that require a change of therapy. Findings should be interpreted with caution due to the limited number of studies. A large-sized prospective clinical trial is warranted to support evidence-based decision-making.

Novel robotic TCD ultrasound with bubbles versus standard care to detect right to left shunt: Study methods

BACKGROUND AND PURPOSE

Right to left shunt (RLS), from patent foramen ovale (PFO) or elsewhere, is a recognized risk factor for stroke. Current standard of care for RLS diagnosis includes transthoracic echocardiography (TTE) which is insensitive, transesophageal echocardiography (TEE) which is invasive, and transcranial Doppler (TCD) which has excellent sensitivity and specificity for RLS but is heavily operator dependent and expertise is scarce. The purpose of this study was to evaluate the RLS detection rate of a novel robotic-assisted TCD (ra-TCD) to standard of care diagnostic techniques, including TTE, TEE, and TCD.

METHODS

This is a multicenter, prospective, single-arm, nonsignificant risk device study of ra-TCD versus TTE for RLS diagnosis in adult patients who present with neurological signs and symptoms that include embolic stroke or transient ischemic attack on the differential diagnosis. Up to 150 subjects will be enrolled at up to seven centers considering the prevalence of PFO, suboptimal transtemporal windows, and potential dropouts. Enrolled patients will undergo ra-TCD supine and at 45° in a manner otherwise in line with standard of care TCD bubble technique. The enrolled patients will have undergone TTE, and optionally standard TCD and TEE, per usual care.

RESULTS

The primary efficacy endpoint is percent detection of RLS by ra-TCD compared against TTE. The primary safety endpoint is the incidence of device-related serious adverse events.

CONCLUSIONS

This is the first multicenter, prospective study evaluating the accuracy, feasibility, and safety of novel ra-TCD for the diagnosis of RLS as compared to standard of care diagnostics.

Comparing the diagnostic value of Echocardiography In Stroke (CEIS) - results of a prospective observatory cohort study

BACKGROUND

Echocardiography is one of the main diagnostic tools for the diagnostic workup of stroke and is already well integrated into the clinical workup. However, the value of transthoracic vs. transesophageal echocardiography (TTE/TEE) in stroke patients is still a matter of debate. Aim of this study was to characterize relevant findings of TTE and TEE in the management of stroke patients and to correlate them with subsequent clinical decisions and therapies.

METHODS

We evaluated n = 107 patients admitted with an ischemic stroke or transient ischemic attack to our stroke unit of our university medical center. They underwent TTE and TEE examination by different blinded investigators.

RESULTS

Major cardiac risk factors were found in 8 of 98 (8.2%) patients and minor cardiac risk factors for stroke were found in 108 cases. We found a change in therapeutic regime after TTE or TEE in 22 (22.5%) cases, in 5 (5%) cases TEE leads to the change of therapeutic regime, in 4 (4%) TTE and in 13 cases (13.3%) TTE and TEE lead to the same change in therapeutic regime. The major therapy change was the indication to close a patent foramen ovale (PFO) in 9 (9.2%) patients with TTE and in 10 (10.2%) patients with TEE (p = 1.000).

CONCLUSION

Major finding with clinical impact on therapy change is the detection of PFO. But for the detection of PFO, TTE is non inferior to TEE, implicating that TTE serves as a good screening tool for detection of PFO, especially in young age patients.

TRIAL REGISTRATION

The trial was registered and approved prior to inclusion by our local ethics committee (1/3/17).

Who Should Rather Undergo Transesophageal Echocardiography to Determine Stroke Etiology: Young or Elderly Stroke Patients?

Introduction: The indication of transesophageal echocardiography (TEE) in acute stroke is unclear. Thus, we systematically studied the impact of TEE on determining stroke etiology and secondary prevention in patients of different age-groups with cryptogenic stroke.

Methods: Four hundred and eighty five consecutive patients with acute retinal or cerebral ischemia were prospectively included and underwent routine stroke workup including TEE. Stroke etiology was identified according to the TOAST classification and patients were divided in those with determined and cryptogenic stroke etiology without TEE results. Then, the frequency of high- and potential-risk sources in TEE was evaluated in <55, 55–74, and ≥75 year-old patients with cryptogenic stroke etiology.

Results: Without TEE, stroke etiology was cryptogenic in 329(67.8%) patients and TEE determined possible etiology in 158(48.4%) of them. In patients aged <55, 55–74, ≥75, TEE detected aortic arch plaques ≥4 mm thickness in 2(1.2%), 37(23.0%), and 33(40.2%) and plaques with superimposed thrombi in 0(0.0%), 5(3.1%), and 7(8.5%); left atrial appendage peak emptying flow velocity ≤30cm/s in 0(0.0%), 1(0.6%), and 2(2.4%), spontaneous echo contrast in 0(0.0%), 1(0.6%), and 6(7.3%), endocarditis in 0(0.0%), 0(0.0%), and 1(1.2%) and patent foramen ovale (PFO) plus atrial septum aneurysm (ASA) in 18(20.9%), 32(19.9%), and 14(17.1%), respectively. TEE changed secondary prevention in 16.4% of these patients following guidelines of 2010/11 and still 9.4% when applying the guidelines of 2020.

Conclusions: TEE was highly valuable for determining stroke etiology and influenced individual secondary prevention based on available treatment guidelines and expert opinion in most cases. In young patients the impact of TEE was limited to the detection of septal anomalies. By contrast, in older patients TEE detected high numbers of complex aortic atheroma and potential indicators of paroxysmal atrial fibrillation.

The Value of Contrast-Enhanced Transesophageal Echocardiography in the Detection of Cardiac Right-to-Left Shunt Related with Cryptogenic Stroke and Migraine

Purpose

To analyze the characteristics of right-to-left shunt (RLS) in patients with cryptogenic stroke and migraine by contrast-enhanced transesophageal echocardiography (c-TEE).

Methods

The study population consisted of 330 patients with cryptogenic stroke and 330 patients with migraine who suspected PFO. All of them received c-TEE examination successfully. In terms of c-TEE analyses, RLS could be diagnosed when microbubbles were visualized in the transition from the right atrium to the left atrium. For semiquantitative analysis, a small amount of RLS was grade 1, indicating 1-10 microvesicles per frame could be seen in the left atrium, a moderate amount of RLS was grade 2, indicating 11-30 microvesicles per frame could be seen in the left atrium, and a large amount of RLS was grade 3, indicating more than 30 microvesicles per frame, or the left atrium is filled with microvesicles.

Results

A total of 660 patients were analyzed in the study. PFO-RLS was detected in 348 (348/660, 52.7%) cases by TEE, while in 392 (392/660, 59.3%) cases by c-TEE. Simultaneously, P-RLS was detected in 239 (239/660, 36.2%) cases by c-TEE. Among 330 patients with cryptogenic stroke, PFO-RLS was detected in 198 cases; according to the c-TTE method (198/330, 60.0%), concurrently, 83 participants suffered from PFO-RLS and P-RSL (83/330, 25.1%), including 1 case with PFO and pulmonary arteriovenous fistula. Among 330 patients with migraine, PFO-RLS was detected in 194 cases; according to the c-TTE method (194/330, 58.7%), specifically, 90 participants suffered from PFO-RLS and P-RSL (90/330, 27.2%). There was no statistical significance between the two groups. P-RLS singly was detected in 28 cases with cryptogenic stroke, while in 38 cases with migraine, excluding from pulmonary arteriovenous fistula by CTA examination. In addition, semiquantitative results on c-TTE grading of RLS were compared between the two groups: grade 1 RLS in the migraine group (144/322) was significantly higher than that in the cryptogenic stroke group (71/309) (P < 0.05). Grade 3 RLS in the cryptogenic stroke group (113/309) was significantly higher than that in the migraine group (67/322) (P < 0.05). For grade 2 RLS, there was no statistical difference between the two groups (P = 0.12).

Conclusions

c-TEE can increase the positive rate of PFO diagnosis compared with TEE color Doppler. There is no significant difference in the incidence of PFO-PLS and P-RLS between the cryptogenic stroke group and the migraine group. The grades 2-3 RLS are mainly detected in the cryptogenic stroke group, while grades 1-2 RLS are mostly detected in the migraine group.

Atherosclerotic plaque detected by transesophageal echocardiography is an independent predictor for all-cause mortality

Atherosclerotic lesions in the great arteries are frequent findings in the elderly. Numerous studies have shown their strong predictive value for cardiovascular disease, embolic events, and mortality. We sought to determine the risk of all-cause mortality depending on the localization of plaques in the thoracic aorta evaluated by transesophageal echocardiography (TEE). A total of 2,054 patients (median age 65 years, interquartile range 52–73; 58% men) who underwent a TEE examination between 01/2007 and 03/2015 were retrospectively analyzed. For each patient, the presence of atherosclerotic lesions in the ascending aorta, the aortic arch, and in the descending aorta, as well as cardiovascular risk factors and survival were documented. Median follow-up period was 48 months (interquartile range 38–58). Multivariate Cox regression analysis indicated plaque in the ascending aorta (HR of 1.36, 95% CI 1.01–1.83, P = 0.046), the aortic arch (HR of 1.78, 95% CI 1.29–2.45, P < 0.001), the descending aorta (HR of 2.01, 95% CI 1.54–2.77, P < 0.001), and plaque in any part of the thoracic aorta (HR of 1.84, 95% CI 1.42–2.4, P < 0.001), as independent predictors for all-cause mortality after adjusting for age, sex, arterial hypertension, hyperlipidemia, smoking, and diabetes. In this study, we could demonstrate that more than mild plaque at any site of the thoracic aorta predicts all-cause mortality. Assessment of atherosclerotic lesions in all segments of the thoracic aorta should be part of every routine TEE examination.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Roles of Transesophageal Echocardiography and Cardiac Computed Tomography for Evaluation of Left Atrial Thrombus and Associated Pathology: A Review and Critical Analysis

Evaluation of the left atrium and left atrial appendage for the presence of thrombus prior to cardioversion and pulmonary vein isolation, and of the entire heart for embolic sources in the setting of cryptogenic stroke, has long been standard medical care. Guidelines have uniformly recommended transesophageal echocardiography (TEE) to accomplish these goals. In recent years, computed tomographic angiography has demonstrated diagnostic accuracy similar to that of TEE for the detection of thrombus. Analysis of the pertinent data and relative merits of the 2 technologies leads to the conclusions that: 1) both modalities have some unique, nonoverlapping capabilities that may dictate their use in specific situations; 2) computed tomographic angiography is a reasonable alternative to TEE when the primary aim is to exclude left atrial and left atrial appendage thrombus and in patients in whom the risks associated with TEE outweigh the benefits; and 3) both options should be discussed with the patient in the setting of shared decision making.

Embolic strokes of undetermined source: theoretical construct or useful clinical tool?

In 2014, the definition of embolic strokes of undetermined source (ESUS) emerged as a new clinical construct to characterize cryptogenic stroke (CS) patients with complete vascular workup to determine nonlacunar, nonatherosclerotic strokes of presumable embolic origin. NAVIGATE ESUS, the first phase III randomized-controlled, clinical trial (RCT) comparing rivaroxaban (15 mg daily) with aspirin (100 mg daily), was prematurely terminated for lack of efficacy after enrollment of 7213 patients. Except for the lack of efficacy in the primary outcome, rivaroxaban was associated with increased risk of major bleeding and hemorrhagic stroke compared with aspirin. RE-SPECT ESUS was the second phase III RCT that compared the efficacy and safety of dabigatran (110 or 150 mg, twice daily) to aspirin (100 mg daily). The results of this trial have been recently presented and showed similar efficacy and safety outcomes between dabigatran and aspirin. Indirect analyses of these trials suggest similar efficacy on the risk of ischemic stroke (IS) prevention, but higher intracranial hemorrhage risk in ESUS patients receiving rivaroxaban compared to those receiving dabigatran (indirect HR = 6.63, 95% CI: 1.38-31.76). ESUS constitute a heterogeneous group of patients with embolic cerebral infarction. Occult AF represents the underlying mechanism of cerebral ischemia in the minority of ESUS patients. Other embolic mechanisms (paradoxical embolism via patent foramen ovale, aortic plaque, nonstenosing unstable carotid plaque, etc.) may represent alternative mechanisms of cerebral embolism in ESUS, and may mandate different management than oral anticoagulation. The potential clinical utility of ESUS may be challenged since the concept failed to identify patients who would benefit from anticoagulation therapy. Compared with the former diagnosis of CS, ESUS patients required thorough investigations; more comprehensive diagnostic work-up than is requested in current ESUS diagnostic criteria may assist clinicians in uncovering the source of brain embolism in CS patients and individualize treatment approaches.

Left ventricular wall motion abnormality is associated with cryptogenic stroke

BACKGROUND

Left ventricular wall motion abnormality (LVWMA) unrelated to known cardiac risk factors is an uncertain risk for stroke.

AIMS

We evaluated whether LVWMA was associated with cryptogenic stroke.

METHODS

This retrospective, observational study included 4316 acute ischemic stroke patients, and the association between cryptogenic stroke and LVWMA was examined in comparison with other stroke subtypes.

RESULTS

The prevalence of LVWMA was 10.0% in the study population. In a fully adjusted, binary logistic regression, LVWMA was independently associated with cryptogenic stroke compared with stroke from large artery atherosclerosis (odds ratio = 1.627, 95% confidence interval = 1.129-2.345), small vessel occlusion (odds ratio = 1.948, 95% confidence interval = 1.261-3.010), or other causes (odds ratio = 4.950, 95% confidence interval = 1.145-21.412). Meanwhile, the association of LVWMA with cryptogenic stroke was similar to the associations of LVWMA with cardioembolic stroke (odds ratio = 0.758, 95% confidence interval = 0.525-1.094) and stroke with two or more causes (odds ratio = 0.992, 95% confidence interval = 0.609-1.615). In multinomial regression, LVWMA had the strongest association with cardioembolic stroke, followed by cryptogenic stroke and stroke from two or more causes. The strength of the associations with LVWMA then decreased sequentially in patients with large artery atherosclerosis, small vessel occlusion, and other causes.

CONCLUSIONS

The association of LVWMA with cryptogenic stroke was comparable to that of LVWMA with cardioembolic stroke but stronger than that of LVWMA with non-cardioembolic stroke. LVWMA unrelated to known cardiac risk factors could be considered an independent risk factor for cryptogenic stroke.

Echocardiographic features of PFOs and paradoxical embolism: a complicated puzzle

Patent foramen ovale (PFO) is a residual, oblique, slit or tunnel like communication in the atrial septum that persists into adulthood. It is usually an incidental finding with no clinical repercussions. Nevertheless, recent evidence supports the association between the presence of a PFO and a number of clinical conditions, most notably cryptogenic stroke (CS). There is enough evidence that paradoxical embolism is a mechanism which can explain this association. Patient characteristics and certain echocardiography-derived anatomical and hemodynamic features of PFO provide great assistance in estimating the probability of paradoxical embolism. In this review, we initially describe PFO embryology and anatomy. We extensively present the available data on clinical, anatomical and hemodynamic features of PFOs which have been correlated with increased likelihood of paradoxical embolism and recent evidence of therapeutic management.

Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages: a population-based study, systematic review, and meta-analysis

BACKGROUND

Percutaneous closure of patent foramen ovale (PFO) has been shown to be superior to medical treatment alone for prevention of recurrent stroke after cryptogenic transient ischaemic attack or non-disabling stroke in patients aged 60 years or younger. The justification for trials in older patients with transient ischaemic attack or stroke depends on whether PFO is shown to be associated with cryptogenic events at older ages, for which existing evidence is conflicting, and on the population burden of PFO-associated events. Therefore, we did a population-based screening study using contrast-enhanced transcranial Doppler (bubble-TCD) to detect probable PFO as indicated by a right-to-left shunt (RLS); we also did a systematic review and meta-analysis to compare our results with previous studies.

METHODS

In this population-based study, nested in the Oxford Vascular Study (OXVASC), we established the prevalence of any RLS, and of large RLS (>20 microbubbles), in consecutive patients attending a rapid-access transient ischaemic attack and stroke clinic, or at 1-month follow-up after stroke unit admission, with transient ischaemic attack or non-disabling ischaemic stroke, comparing cryptogenic events with those of known cause (according to Trial of Org 10172 in Acute Stroke Treatment [TOAST] criteria). We stratified participants by age, and extrapolated data to the UK population. We also did a systematic review of published studies of PFO prevalence (using transthoracic or transoesophageal echocardiography or bubble-TCD) according to stroke subtype, which included older patients and reported age-specific results, and determined by meta-analysis (including the OXVASC data) the pooled odds ratio (95% CI) of finding PFO of any size in cryptogenic events compared with events of known cause, stratified by screening modality (transthoracic or transoesophageal echocardiography or bubble-TCD). The study protocol is registered with PROSPERO, number CRD42018087074.

FINDINGS

Among 572 consecutive patients with transient ischaemic attack or non-disabling stroke between Sept 1, 2014, and Oct 9, 2017 (439 [77%] patients aged >60 years, mean age 70·0 years [SD 13·7]), bubble-TCD was feasible in 523 patients (91%) of whom 397 were aged older than 60 years. Compared with those with transient ischaemic attack or stroke of known cause, patients with cryptogenic events had a higher prevalence of RLS overall (odds ratio [OR] 1·93, 95% CI 1·32-2·82; p=0·001), and in those aged older than 60 years (2·06, 1·32-3·23; p=0·001). When we pooled the OXVASC data with that from two previous smaller studies of bubble-TCD in patients aged 50 years or older, we found an association between RLS and cryptogenic events (OR 2·35, 95% CI 1·42-3·90; p=0·0009; pheterogeneity=0·15), which was consistent with the equivalent estimate from transoesophageal echocardiography studies (2·20, 1·15-4·22; p=0·02; pheterogeneity=0·02). No data on large RLS in patients with TOAST-defined cryptogenic events compared with other events were available from previous studies, but we found no evidence that the association was diminished in such cases. Of 41 patients with large RLS and cryptogenic transient ischaemic attack or non-disabling stroke in our study, 25 (61%) were aged older than 60 years, which extrapolates to 5951 patients per year in the UK (data from mid-2016).

INTERPRETATION

Bubble-TCD was feasible in most older patients with transient ischaemic attack or non-disabling stroke, the association of RLS with cryptogenic events remained at older ages, and the population burden of PFO-associated events is substantial. Randomised trials of PFO closure at older ages are required and should be feasible.

FUNDING

National Institute for Health Research, Oxford Biomedical Research Centre, Wellcome Trust, and Wolfson Foundation.

Percutaneous patent foramen ovale closure for secondary stroke prevention: Network meta-analysis

OBJECTIVE

Current guidelines report no benefit for patent foramen ovale (PFO) closure compared to medical treatment in patients with cryptogenic ischemic stroke (IS) or TIA. Two recent randomized controlled clinical trials have challenged these recommendations.

METHODS

We performed a systematic review and network meta-analysis of randomized controlled trials to estimate the safety and efficacy of closure compared to medical treatment, and to compare available devices. We conducted pairwise meta-analyses for closure vs medical therapy, irrespective of the device used, and for each device vs medical therapy.

RESULTS

Our literature search highlighted 6 studies. PFO occlusion was associated with reduced risk of recurrent IS (risk ratio [RR] 0.42, 95% confidence interval [CI] 0.20-0.91) and IS/TIA (RR 0.65, 95% CI 0.48-0.88) but with increased risk of new-onset atrial fibrillation (AF) (RR 4.59, 95% CI 2.01-10.45) compared to medical treatment. In indirect analyses, both Amplatzer (AMP) and GORE devices were found to be associated with a lower risk of new-onset AF compared to STARFlex (SFX) (RR 0.25, 95% CI 0.10-0.65 and RR 0.28, 95% CI 0.08-0.95). Moreover, AMP was found to be associated with a lower risk of recurrent IS/TIA events compared to the SFX device (RR 0.35, 95% CI 0.14-0.91). In the clustered ranking plot on the risk of IS against new-onset AF, GORE was comparable to AMP; however, on the risk of IS/TIA against new-onset AF, AMP appeared to be superior to the GORE device. In both ranking plots, SFX was highlighted as the worst option.

CONCLUSION

PFO closure is associated with reduced risk of recurrent IS or IS/TIA and with increased risk of new-onset AF.

2017 Update on Medical Overuse: A Systematic Review

Importance

Overuse of medical care is a well-recognized problem.

Objective

To identify and highlight original research articles published in 2016 that are most relevant to understanding medical overuse or strategies to reduce it.

Evidence Review

A structured review of English-language articles on PubMed published in 2016 coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adults. These articles were appraised for their importance to medicine.

Findings

This study considered 2252 articles, 1224 of which addressed medical overuse. Of these, 122 were deemed most relevant based on originality, methodologic quality, and number of patients potentially affected. The 10 most influential articles were selected by author consensus. Select findings from the studies include the lack of benefit of transesophageal echocardiography in the workup of cryptogenic stroke, increasing use of computed tomography in the emergency department from 2.2% to 9.4% from 2001 to 2010, and carotid ultrasonography and revascularization being performed for uncertain or inappropriate indications with 95% frequency. Likewise, services for which harms are likely to outweigh benefits include treatment for early-stage prostate cancer, which provides no mortality benefit but increases absolute risk of erectile dysfunction by 10% to 30%, oxygen for patients with moderate chronic obstructive pulmonary disease, surgery for meniscal tear with mechanical symptoms, and nutritional interventions for inpatients with malnutrition. This review highlights 2 methods for reducing overuse: clinician audit and feedback with peer comparison for antibiotic use (reduction in inappropriate antibiotic use from 20% to 4%) and a practical and sensible shared decision-making tool for low-risk chest pain (reduction in emergency department workup from 52% to 37%).

Conclusions and Relevance

The body of empirical work continues to expand related to medical services that are provided for inappropriate or uncertain indications. Engaging patients in conversations aimed at shared decision making and giving practitioners feedback about their performance relative to peers appear to be useful in reducing overuse.

Cardiac Tumors: Echocardiographic Diagnosis and Forensic Correlations

In the past, cardiac tumors were a just clinical curiosity and the prognosis was poor. Surgical management became possible after the advent of cardiopulmonary bypass, and more recently, preoperative diagnosis was greatly improved by the development of echocardiography, computed tomography, and magnetic resonance imaging. The value of echocardiography for diagnosing cardiac mass lesions has become well established. Numerous advances have occurred in the last 5 decades, and the evolution of echocardiography involves the development of its many modalities. This review is intended to help echocardiologists and forensic pathologists in providing good medical practice when faced with the challenge of investigating unexpected clinical signs, particularly in young people, or unexpected postmortem findings.

Stroke prevention

Patients who have had a stroke are at high risk for recurrent stroke, myocardial infarction, and vascular death. Prevention of these events should be initiated promptly after stroke, because many recurrent events occur early, and should be tailored to the precise cause of stroke, which may require specific treatment. Lifestyle advice including abstinence from smoking, regular exercise, Mediterranean-style diet, and reduction of salt intake and alcohol consumption are recommended for all patients with stroke. For most patients with ischemic stroke or TIA, control of risk factors, including lowering blood pressure under 140/90mmHg and LDL cholesterol under 1g/L, together with antiplatelet or oral anticoagulant therapy, depending on the cause of stroke, have been shown to decrease the risk of recurrent stroke and cardiovascular events. Aspirin, clopidogrel, or the combination of aspirin and dipyridamole, are all acceptable options for secondary prevention in patients with ischemic stroke or TIA of arterial origin. Dual therapy with aspirin and clopidogrel might be considered for 3 weeks after a minor ischemic stroke or TIA and for 3 months in patients with stroke due to severe intracranial stenosis. Oral anticoagulants are very effective to prevent cardioembolic stroke. Non-VKA oral anticoagulants have a favorable risk-benefit profile compared with VKAs, with significant reductions in stroke, intracranial hemorrhage, mortality, with similar major bleeding, but increased gastrointestinal bleeding. Carotid endarterectomy reduces the risk of ipsilateral stroke in patients with recent (<6 months) non disabling ischemic stroke or TIA in the territory and severe carotid artery stenosis. Carotid stenting is a potential alternative to surgery in patients younger than ≈70 years or patients with greater risk of surgery due to anatomic or medical conditions or specific circumstances such as radiation-induced stenosis or restenosis after surgery. For patients with hemorrhagic stroke due to hypertension-associated small vessel disease or cerebral amyloid angiopathy, strict control of blood pressure is essential. Restarting oral anticoagulants in patients after intracranial hemorrhage is a difficult decision that should weigh the risks of recurrent ischemic and hemorrhage stroke with and without oral anticoagulants. Several areas of uncertainty persist including the optimal target of blood pressure in patients with cerebrovascular disease, the benefit of PFO closure in patients with PFO-associated stroke, of stenting procedures in patients with atherosclerotic intracranial artery or extracranial vertebral artery stenosis, and of interventional procedures in patients with brain arteriovenous or cavernous malformations.

The value of transesophageal echocardiography for embolic strokes of undetermined source

OBJECTIVE

Our aim was to evaluate the diagnostic yield of transesophageal echocardiography (TEE) in consecutive patients with ischemic stroke (IS) fulfilling the diagnostic criteria of embolic strokes of undetermined source (ESUS).

METHODS

We prospectively evaluated consecutive patients with acute IS satisfying ESUS criteria who underwent in-hospital TEE examination in 3 tertiary care stroke centers during a 12-month period. We also performed a systematic review and meta-analysis estimating the cumulative effect of TEE findings on therapeutic management for secondary stroke prevention among different IS subgroups.

RESULTS

We identified 61 patients with ESUS who underwent investigation with TEE (mean age 44 ± 12 years, 49% men, median NIH Stroke Scale score = 5 points [interquartile range: 3-8]). TEE revealed additional findings in 52% (95% confidence interval [CI]: 40%-65%) of the study population. TEE findings changed management (initiation of anticoagulation therapy, administration of IV antibiotic therapy, and patent foramen ovale closure) in 10 (16% [95% CI: 9%-28%]) patients. The pooled rate of reported anticoagulation therapy attributed to abnormal TEE findings among 3,562 acute IS patients included in the meta-analysis (12 studies) was 8.7% (95% CI: 7.3%-10.4%). In subgroup analysis, the rates of initiation of anticoagulation therapy on the basis of TEE investigation did not differ (p = 0.315) among patients with cryptogenic stroke (6.9% [95% CI: 4.9%-9.6%]), ESUS (8.1% [95% CI: 3.4%-18.1%]), and IS (9.4% [95% CI: 7.5%-11.8%]).

CONCLUSIONS

Abnormal TEE findings may decisively affect the selection of appropriate therapeutic strategy in approximately 1 of 7 patients with ESUS.

Transcranial Doppler versus transthoracic echocardiography for the detection of patent foramen ovale in patients with cryptogenic cerebral ischemia: A systematic review and diagnostic test accuracy meta-analysis

OBJECTIVE

Patent foramen ovale (PFO) can be detected in up to 43% of patients with cryptogenic cerebral ischemia undergoing investigation with transesophageal echocardiography (TEE). The diagnostic value of transthoracic echocardiography (TTE) in the detection of PFO in patients with cryptogenic ischemic stroke or transient ischemic attack has not been compared with that of transcranial Doppler (TCD) using a comprehensive meta-analytical approach.

METHODS

We performed a systematic literature review to identify all prospective observational studies of patients with cryptogenic cerebral ischemia that provided both sensitivity and specificity measures of TTE, TCD, or both compared to the gold standard of TEE.

RESULTS

Our literature search identified 35 eligible studies including 3,067 patients. The pooled sensitivity and specificity for TCD was 96.1% (95% confidence interval [CI] = 93.0-97.8%) and 92.4% (95% CI = 85.5-96.1%), whereas the respective measures for TTE were 45.1% (95% CI = 30.8-60.3%) and 99.6% (95% CI = 96.5-99.9%). TTE was superior in terms of higher positive likelihood ratio values (LR+ = 106.61, 95% CI = 15.09-753.30 for TTE vs LR+ = 12.62, 95% CI = 6.52-24.43 for TCD; p = 0.043), whereas TCD demonstrated lower negative likelihood values (LR- = 0.04, 95% CI = 0.02-0.08) compared to TTE (LR- = 0.55, 95% CI = 0.42-0.72; p < 0.001). Finally, the area under the summary receiver operating curve (AUC) was significantly greater (p < 0.001) in TCD (AUC = 0.98, 95% CI = 0.97-0.99) compared to TTE studies (AUC = 0.86, 95% CI = 0.82-0.89).

INTERPRETATION

TCD is more sensitive but less specific compared to TTE for the detection of PFO in patients with cryptogenic cerebral ischemia. The overall diagnostic yield of TCD appears to outweigh that of TTE.

The value of transesophageal echocardiography in the investigation and management of cryptogenic cerebral ischemia: a single-center experience

The diagnostic utility of transesophageal echocardiography (TEE) has often been challenged in patients with cryptogenic stroke (CS). We estimated the prevalence of different findings on TEE examination of CS patients, their impact on secondary stroke prevention and the presence of potential age or gender disparities. We reviewed all TEE examinations that were performed in a single echocardiography laboratory during a 7-year-old period to identify CS patients that underwent investigation with TEE. Of the 518 total TEE examinations, we identified 88 CS patients. TEE revealed abnormal findings in 69.3 % of them. Patent foramen ovale (PFO) and atrial septal aneurysm (ASA) were identified in 30.6 and 22.7 % of the patients. Ascending aorta and aortic arch atheromatosis was present in 26.1 % of the patients, with complex atheromatosis diagnosed in 14.7 % of them. Cardiac myxomas were uncovered in 2.3 %. Thrombi in the left atrium and in cardiac valves were reported in 3.4 and 2.3 % of the patients, respectively. Based on TEE findings, the therapeutic management would be very likely modified in 9.1 % of the patients. Subgroup analysis revealed no gender disparities on the prevalence of TEE findings and in secondary stroke prevention, while linear regression analyses revealed significant associations of age with the prevalence of PFO, ASA, aorta atheromatosis and complex aorta atheromatosis. TEE examination should be included in the diagnostic work-up of all CS patients, irrespective of age and gender status, since it can reveal potential sources of embolism and has a significant impact for secondary stroke prevention.