To evaluate the necessity of transesophageal echocardiography (TEE) in the diagnostic work-up of juvenile cryptogenic stroke, transient ischemic attack (TIA), and amaurosis fugax.

The ratio of patients with clinically significant findings in TEE after stroke or TIA varied between 0-30% in prior studies, but is low in patients ≤ 60 years. Previous studies have shown that complex aortic plaques are unlikely in the absence of carotid atherosclerosis. Paradoxical embolism can be ruled out reliably via transcranial bubble study. Therefore, it is unclear in which cases of juvenile stroke, TIA or amaurosis fugax, TEE is indicated.

In this ongoing prospective clinical study, patients ≤ 60 years with embolic stroke, TIA, or amaurosis fugax are included if the etiology is undetermined after completion of routine diagnostics. Exclusion criteria are atrial fibrillation/flutter, dissection or ≥ 50% stenosis of the supplying artery, vasculitis with central nervous system involvement, suspected endocarditis, and lacunar stroke in the presence of pronounced white matter hyperintensities. All patients undergo TEE and standardized ultrasound of intima-media-thickness (IMT) of the common carotid artery (CCA), atherosclerotic plaque detection of the internal and external carotid artery (ICA/ECA), and transcranial bubble-test for detection of right-to-left shunt. Both examiners of TEE and neurovascular ultrasound are blinded for the other diagnostic results.  

Within one year, 160 consecutive patients (41% female, 59% male) were included (66% stroke, 28% TIA, 6% amaurosis fugax). Prevalence of complex aortic plaques, PFO, or other therapy-relevant findings in TEE was 40%. The combination of CCA IMT, existence of ICA/ECA plaques, and transcranial bubble-test yielded 95% sensitivity and 93% negative predictive value for therapy-relevant TEE findings.

In patients ≤ 60 years with cryptogenic embolic stroke, TIA or amaurosis fugax, non-invasive neurovascular ultrasound has high sensitivity and negative predictive value for therapy-relevant TEE findings and can therefore serve as selection criteria for performing TEE.