Difference Among Embolic Sources Between Younger and Older Patients With Stroke of Undetermined Source on Routine Diagnostic Assessment Including Transesophageal Echocardiography

Abstract

Background: The distribution of embolic sources in patients with embolic stroke of undetermined source (ESUS) remains unclear. Furthermore, the difference among embolic sources according to age is unknown. The aim of this study was to identify the distribution of embolic sources in younger and older patients with embolic strokes who underwent routine diagnostic assessment with transesophageal echocardiography (TEE) and to evaluate the distribution of paradoxical embolism related to patent foramen ovale (PFO) between younger and older.

Methods and Results: Between May 2012 and December 2017, 102 ESUS patients underwent routine diagnostic assessment including TEE at our hospital to identify the specific cause of their embolic stroke. We compared the causes of embolic stroke between younger (60 years; mean age, 74.8 ± 6.2 years; n=78) patients. Older patients had significantly higher rates of aortic arch atherosclerotic plaques (4.2% vs. 48.7%; p <0.001). The other causes were not significantly different between the two groups. Especially in paradoxical embolism related to PFO, younger patients had fewer other embolic sources in addition to PFO or both PFO and atrial septal aneurysm (ASA) than older patients. However, Introduction Embolic stroke of undetermined source (ESUS) is a form of stroke defined based on a set of criteria proposed by the Cryptogenic Strokes/ESUS International Working Group [1]. Although the causes of ESUS have been previously reported in multiple studies, the cause of stroke could not be identified using the ESUS criteria in a number of patients. Moreover, this Difference Among Embolic Sources Between Younger and Older Patients with Stroke of Undetermined Source on Routine Diagnostic Assessment Including Transesophageal Echocardiography Hiroya Takafuji, MD*, Shinobu Hosokawa, MD, Riyo Ogura, MD, Yoshikazu Hiasa, MD Department of Cardiology, Tokushima Red Cross Hospital, Komatsushima, Tokushima, Japan older patients also exhibited PFO or both PFO and ASA (32.6%) without other embolic sources.

Conclusions: Our study suggests that embolic source of ESUS to undergo routine diagnostic assessment including transesophageal echocardiography (TEE) is similar between younger and older. However, the total numbers of embolic sources is significantly higher in older patients. In paradoxical embolism related to PFO, 33% of older patients had no other identifiable cause of embolic stroke besides a PFO.