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CHAPTER 24: Stroke

GUIDELINES Sources

  • Celeste F, Muratori M, Mapelli M, et al. The evolving role and use of echocardiography in the evaluation of cardiac source of embolism. J Cardiovasc Echogr. 2017;27:33–44.

  • Pepi M, Evangelista A, Nihoyannopoulos P, et al. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism. Eur J Echocardiogr. 2010;11:461–476.

European Guidelines

  • Detailed recommendations for the use of echocardiography.

  • Potential cardioembolic sources.

  • Echocardiographic predictors of embolic risk.

Source

  • Saric M, Armour AC, Arnaout MS, et al. Guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism. J Am Soc Echocardiogr. 2016;29:1–42.

  • Comprehensive, very readable guideline document that discusses all causes of cardioembolic strokes.

  • There are extensive, practical discussions of endocarditis as a source of embolism, embolism from the aorta, cardiac tumors as a source of embolism, and paradoxical and pulmonary embolism, as well as left ventricular and left atrial abnormalities.

ECHO FOR CARDIAC SOURCE OF EMBOLISM

  • Role of echo:

    • - Establish the existence of a potential cardiac source of embolism (intracardiac thrombus, vegetation, aortic atheroma, interatrial communication, left atrial myxoma).

    • - Help determine the likelihood that a stroke came from this source.

Example

  • A patient with a mitral or aortic valve vegetation has a stroke, and the vegetation is now clearly smaller in size compared with an echo before the stroke.

  • This suggests that part of the vegetation broke off and embolized to the brain.

  • Both TTE and TEE imaging are employed.

  • TTE is better for confirming an apical left ventricular thrombus.

  • Findings on TTE may suggest a potential cardiac source of embolism and may require TEE for confirmation.

  • TEE is better for diagnosing:

    • - Thrombus in the left atrial appendage.

    • - Imaging Tip: See Figures 24-1 to 24-5 for examples of stroke-related TEE information about the left atrial appendage. The challenge for the sonographer is to reproduce some of these TEE findings on transthoracic imaging. This requires creating high resolution 2D and 3D transthoracic images of the left atrial appendage. Imaging angle should also be adjusted with the help of color Doppler so that the pulsed wave Doppler sample volume at the mouth of the appendage is as parallel to blood flow as possible.

    • - Atheromas in the aorta—usually found by TEE in the descending thoracic aorta and aortic arch (far less frequently confirmed by TEE in the ascending aorta).

    • - Patent foramen ovale—visualized on TEE, but saline contrast with cough and Valsalva also should be done with TTE.

    • - Vegetations—better detail on TEE. TEE exam has to be meticulous. Can be missed on TTE.

  • TEE is likely to help after TTE if:

    • - TTE images are suboptimal.

    • - Patient is young, has no previous cardiac condition, and PFO is suspected.

    • - Prosthetic valve is present.

    • - Atrial fibrillation is known or suspected.

    • - Mitral stenosis is present (suspect an LAA thrombus).

  • Mobile masses on an aortic ...

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