Which ischemic stroke patients need a TEE?

The main reason for getting a TEE in a patient with ischemic stroke is to find out if that patient has an indication for warfarin anticoagulation. You can begin the selection process by excluding patients who already have an obvious indication for warfarin (e.g. atrial fibrillation) and those who have a contraindication for warfarin.

Among the remaining patients only those with cryptogenic stroke are likely to need a TEE. I previously linked to a paper demonstrating a high yield for TEE in finding an indication for warfarin in such patients. Here is a new study documenting similar findings:

Results: 702 consecutive patients (380 male, 383 IS, 319 TIA, age 18–90 years) were included. In 52.6% of all patients, TEE examination revealed relevant findings. Overall, the most common findings in all patients were: patent foramen ovale (21.7%), previously undiagnosed valvular disease (15.8%), aortic plaques, aortic valve sclerosis, atrial septal aneurysms, regional myocardial dyskinesia, dilated left atrium and atrial septal defects. Older patients (greater than 55 years, n = 291) and patients with IS had more relevant echocardiographic findings than younger patients or patients with TIA, respectively (p = 0.002, p = 0.003). The prevalence rates of PFO or ASD were higher in younger patients (PFO: 26.8% vs. 18.0%, p = 0.005, ASD: 9.6% vs. 4.9%, p = 0.014).

All in all, based on these two studies, a third to half of patients with cryptogenic stroke are found to have potential indications for warfarin anticoagulation.

Background: The TOAST classification may be helpful in the determination of cryptogenic stroke.