Stroke, TIA & peripheral embolism
Find the cardioembolic source: AF and the LA appendage, LV thrombus, vegetations, tumours, PFO and the aortic arch.
Echo approach, step by step
About a quarter of ischaemic strokes are cardioembolic. Echocardiography is recommended to look for a cardiac source when it will change management [176,197]. TTE is the first test. TOE is superior for the LA appendage, the atrial septum, the aortic arch and small valvular lesions [176].
- LVApical thrombus (contrast), akinetic segments, low EF [140].
- LA and appendageLA size, spontaneous echo contrast; LAA thrombus needs TOE [176].
- ValvesVegetations, rheumatic MS, prosthetic thrombosis, papillary fibroelastoma [136,167,176].
- MassesMyxoma [176].
- Atrial septumPFO (saline at rest and with Valsalva), atrial septal aneurysm [175,176].
- Aortic archAtheroma ≥4 mm or mobile plaque (TOE) [176].
- AortaDissection extending into the carotids [9].
- LV thrombus / low EF
- LA size; LAA (TOE)
- Valves and vegetations
- Mass
- PFO and septal aneurysm (saline)
- Aortic arch (TOE)
Causes & echo clues
| Source | Echo clue | Management |
|---|---|---|
| Atrial fibrillation | LA enlargement, LAA thrombus (TOE) | Anticoagulation [182] |
| LV thrombus | Apical mass after anterior MI or in DCM | Anticoagulation [140] |
| Infective endocarditis | Vegetation | Antibiotics; surgery; no thrombolysis [136] |
| PFO (paradoxical embolism) | Early bubbles, atrial septal aneurysm | Closure in selected patients ≤60 years [197,209] |
| Myxoma / fibroelastoma | Mass | Surgery [176] |
| Aortic arch atheroma | ≥4 mm or mobile plaque (TOE) | Antiplatelet, statin [176,197] |
| Mechanical valve thrombosis | Restricted occluder, high gradients | Anticoagulation, thrombolysis or surgery [167] |
| Rheumatic MS | Commissural fusion | Vitamin K antagonist [6] |
Clinical pathway to the diagnosis
- Acute stroke pathwayBrain CT or MRI and vascular imaging; thrombolysis or thrombectomy decisions come first.
- Rhythm monitoringECG, telemetry, and prolonged monitoring for paroxysmal AF [182,197].
- TTEIn most patients with ischaemic stroke or TIA [197].
- TOEIf TTE is non-diagnostic and the result would change therapy: young patients, cryptogenic stroke, suspected IE, prosthetic valves [176,197].
- PFO decisionAge ≤60, cryptogenic embolic stroke, high RoPE score, large shunt or septal aneurysm → closure [197,209,210].
Clinical pearls & pitfalls
PitfallStroke may be the first presentation of endocarditis. Check temperature and blood cultures, and look at the valves before anticoagulating [136].
- The RoPE score estimates how likely a PFO is to be causal. High scores (young, no risk factors, cortical infarct) favour a causal PFO [210].
- A negative TTE does not exclude LAA thrombus [176].
- Painless type A dissection can present as stroke. Look at the aortic root [9].
Red flags
- Fever or a new murmur with stroke → endocarditis — thrombolysis and anticoagulation are dangerous [136]
- Stroke with chest or back pain, or pulse deficit → aortic dissection [9]
- Young patient, no vascular risk factors → PFO, dissection, thrombophilia [197,210]