Bubble Test and Carotid Ultrasound to Guide Indication of Transesophageal Echocardiography in Young Patients With Stroke

Ernst Mayerhofer; Dirk Kanz; Brigitte Guschlbauer; Christopher D Anderson; Alexander Asmussen; Sebastian Grundmann; Christoph Strecker; Andreas Harloff

doi:10.3389/fneur.2022.836609

Bubble Test and Carotid Ultrasound to Guide Indication of Transesophageal Echocardiography in Young Patients With Stroke

Front Neurol. 2022 Mar 4:13:836609. doi: 10.3389/fneur.2022.836609. eCollection 2022.

Authors

Ernst Mayerhofer^{1

2}, Dirk Kanz¹, Brigitte Guschlbauer¹, Christopher D Anderson³, Alexander Asmussen⁴, Sebastian Grundmann⁴, Christoph Strecker¹, Andreas Harloff¹

Affiliations

¹ Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany.
² Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
³ Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States.
⁴ Department of Cardiology and Angiology I Heart Center, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg, Germany.

Abstract

Background and purpose: Indication of transesophageal echocardiography (TEE) in patients ≤60 years with brain ischemia is uncertain.

Methods: This prospective double-blinded study included patients with cryptogenic acute ischemic stroke or transient ischemic attack (TIA) ≥18 and ≤60 years. After routine diagnostics, all patients underwent patent foramen ovale (PFO) screening by transcranial Doppler (TCD) bubble test, carotid ultrasound for atherosclerosis screening (intima-media-thickness >0.90 mm or plaques), and TEE. We calculated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) of the combined non-invasive ultrasound to predict therapy-relevant TEE findings.

Results: We included 240 consecutive patients (median 51 years, 39% women) of which 68 (28.3%) had both a negative bubble test and no carotid atherosclerosis. Of these, 66 (97.1%) had unremarkable TEE findings; in one patient a small PFO was found and closed subsequently, in another patient a 4.9 mm thick aortic atheroma was found, and double platelet inhibition initiated. Of the other 172 (71.7%) patients, 93 (54%) had PFO and 9 (5.2%) complex aortic plaques. No other therapy-relevant findings were present in both groups. Non-invasive ultrasound had a sensitivity of 98.0%, specificity of 47.8%, NPV of 97.1%, and PPV of 58.1% for therapy-relevant TEE findings.

Conclusions: Bubble test and carotid ultrasound could be used for the individual decision for/against TEE in patients with cryptogenic stroke ≤60 years. If they are unremarkable, TEE can be omitted with high safety regarding secondary prevention. If bubble test is positive and/or carotid ultrasound shows atherosclerosis, TEE should be carried out if PFO or aortic atheroma are potentially relevant for further patient management.

Keywords: bubble test method; carotid intima-media thickness; diagnostic imaging; ischemic stroke; transesophageal echocardiography (TEE); transient ischemic attack; ultrasound.