Kannan, B (2006) Transesophageal Echocardiography in the Detection of Potential Cardiac Source of Embolism in Young Stroke Patients. Masters thesis, Madras Medical College, Chennai.
|
Text
200100106kannan.pdf Download (1MB) | Preview |
Abstract
INTRODUCTION: Ischemic stroke is one of the major causes of morbidity and mortality in middle and late years of life. The incidence of stroke increases with age, this disability affects many people in their golden years. Stroke is the 3rd leading cause of death preceded only by cardiac disease and malignancy. Cerebrovascular accident is an abrupt onset of non-convulsive and focal necrologic defect. 85% CVA caused by ischemia, out of which 20% of is constituted by cardio embolic stroke. Cardio embolic stroke is defined as non-lacunar stroke with presence of potential cardiac source in the absence of cerebrovascular diseases. It has an unfavourable outcome since it produces larger and more disabling stroke than other subtypes. Cardiac embolic stroke is largely preventable, rendering measures of primary prevention valuable. Once the stroke has occurred the likelihood of recurrence is high, thus secondary prevention is also equally important. The availability of new diagnostic techniques especially transesophageal echocardiography (TEE) has allowed clinicians to identify cardiac source of embolism. TEE is a new application of endocardiography that allows high resolution imaging of atria, atrioventricular valves and aorta by inserting an ultrasonic transducer in the esophagus. Recent studies suggest that transesophageal echocardiography may detect a potential source in upto 65% of patients with cerebral ischemic events or systemic arterial embolism. This study was undertaken to compare the diagnostic yield of transesophageal echocardiography with transthoracic echocardiography in the detection of a cardiac source of embolism in patient with cerebral ischemic events under the age 45 yrs. AIM OF THE STUDY: 1. To compare the diagnostic yield of transesophageal echocardiography with transthoracic echocardiography in the detection of cardiac source of embolism in patients with cerebral ischemic events. 2. To document intracardiac lesions which could have been the source of embolism for ischemic stroke. 3. To evaluate the presence of clots in cardiac chambers. 4. To find out incidence of patent foramen ovale (PFO) in this study population. MATERIALS AND METHODS: Stroke patients admitted in medical wards Govt. General Hospital during the period of June 2005 to March 2006, were selected for this study. Inclusion Criteria: 1. Patients with or without cardiac disease below the age 45 yrs. 2. Patient without any known risk factors for thrombotic stroke. Exclusion criteria: 1) Age >45 yrs. 2) Patient with known risk factors for Atherothrombotic stroke like diabetes mellitus, systemic hypertension, smoking. 3) CT suggestive of haemorrhage. Only inpatients were included in series to ensure that investigation, treatment and follow up of cases are done properly and efficiently Detailed history was taken from patients who where conscious and not aphasic. In unconscious patients, history was taken from a reliable informant. A thorough cardiovascular and neurological examination were carried out. After relevant investigation patients with hypertension, diabetes mellitus hyperlipidemia were excluded from the study. METHODOLOGY: Patients with stroke less than 45 yrs were submitted to CT scan. If scan showed infarction, haemorrhagic transformation or multiple infarcts they were included in the study, pure haemorrhagic stroke were not included. Both transthoracic echocardiography & transesophageal echocardiography were done for all patients, on the same day by cardiologist who has adequate training. Standard parasternal and apical views were obtained using Aloka ultrasonic 2000 interfaced with 5MHZ transducer. Intra venous saline contrast was not given during transthoracic echocardiography. STATISTICAL ANALYSIS: Qualitative data was expressed in frequencies with their percentage. Quantitative data was expressed in mean standard deviation (SD). Qualitative data was analysed (Sex, TTE, TEE) to compare the difference between those with clinical evidence of heart disease and those with no clinical evidence of heart disease by Pearson Chi-square test and Yates corrected chi-square test. Then odds ratio was given with 95% confidence interval. Quantitative data (age) was analysed using student t-test to compare the significant difference between those with clinical evidence of heart disease and those with no clinical evidence of heart disease. SUMMARY: To compare the diagnostic yield of transesophageal echocardiography and transthoracic echocardiography in the detection of potential cardiac source of embolism in young stroke patients, 30 patients with stroke underwent both procedures. Transthoracic echocardiography revealed a potential cardiac source of embolism in 25% (4 patients) all of whom had clinical evidence of heart diseases and 14% (2 patients) who had no clinical evidence of heart disease. In addition to the yield by transthoracic echocardiography, transesophageal echocardiography revealed a potential source of embolism in 56% (9 cases). In patients with clinical evidence of heart disease, cardiac abnormalities additionally detected by transesophageal echocardiography are 2 cases of LA appendage clot, 6 cases of left atrial spontaneous echo contrast and one case of prosthetic valve dysfunction (which is statistically significant). In patients with no clinical evidence of heart disease, transesophageal echocardiography detected one case of patent foramen ovale with atrial septal aneurysm. Thus transesophageal echocardiography is more sensitive than transthoracic echocardiography in detection of potential cardiac source of embolism. CONCLUSION: The prevalence and pattern of cardiac disorder in 30 ischemic stroke patient was studied and analysed. 1. Transesophageal echocardiography is of great value in patients with clinical evidence of heart disease. In patients with no clinical evidence of heart disease transesophageal echocardiography has proved to be useful to detect lesions in small percentage of patients without clinical evidence of heart disease which are not even detected by transthoracic echocardiography. Hence transesophageal echocardiography is superior to transthoracic echocardiography in the detection of cardiac source of embolism in patients with cerebral ischemic event. Since this present study involves only small no. of patients usefulness of TEE in patients with no clinical evidence heart disease needs more studies involving large number of patients. 2. In this study Rheumatic heart disease stands as the foremost source of embolism (36%). Among this mitral valve involvement was found in almost all cases. The highest yield in TEE was associated with atrial fibrillation than without atrial fibrillation. Mitral valve prolapse accounted for 6% of cases of ischemic stroke. Coronary artery disease is an uncommon source of embolism in patients less than 45 yrs. Prosthetic valve is also an important source of embolism. 3. Clots in cardiac chambers was detected only in 10% of cases. 4. Patent foramen ovale was detected in 3% of cases.
| Item Type: | Thesis (Masters) |
|---|---|
| Uncontrolled Keywords: | Transesophageal Echocardiography ; Detection ; Potential Cardiac Source ; Embolism ; Young Stroke Patients. |
| Subjects: | MEDICAL > General Medicine |
| Depositing User: | Subramani R |
| Date Deposited: | 25 Mar 2018 01:38 |
| Last Modified: | 25 Mar 2018 03:14 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/6546 |
Actions (login required)
 |
View Item |
