What should be checked in a 2D (two-dimensional) echocardiogram for a stroke patient?

What to Check in 2D Echocardiography for Stroke Patients

In stroke patients, 2D echocardiography should be performed selectively—not routinely—and is most valuable for evaluating potential cardiac sources of embolism in patients with cryptogenic stroke, particularly younger adults, or when clinical suspicion of cardiac disease exists. 1

Primary Indications for Echocardiography in Stroke

Echocardiography is reasonable in patients with cryptogenic stroke to evaluate for possible cardiac sources of or transcardiac pathways for cerebral embolism. 1 The key clinical scenarios include:

• Suspected embolic stroke with normal neurovascular imaging - particularly relevant for younger adults with stroke or TIA of unknown etiology 1
• Cryptogenic stroke where no clear vascular or other cause is identified 1
• Clinical or laboratory evidence of underlying heart disease 2
• Suspected infectious endocarditis 2

Specific Cardiac Sources to Evaluate

Ventricular Sources

Transthoracic echocardiography (TTE) excels at identifying ventricular sources, including: 1

• Left ventricular thrombus - particularly in patients with anterior wall myocardial infarction or cardiomyopathy 1, 3
• Dyskinetic ventricular wall segments suggesting prior infarction 1
• Regional wall motion abnormalities that may indicate acute ischemia or stunning 1
• Global left ventricular systolic dysfunction - an independent prognostic variable for both short- and long-term cardiac events 1

Atrial and Valvular Sources

For atrial and aortic arch sources, transesophageal echocardiography (TEE) is superior to TTE, though TTE should be performed first as the initial less-invasive test: 1

• Patent foramen ovale (PFO) - a potential transcardiac pathway for paradoxical embolism 1
• Atrial septal defects or atrial septal aneurysm 1, 4
• Left atrial or left atrial appendage thrombus - especially in atrial fibrillation 1, 3
• Mitral valve abnormalities including stenosis, prolapse, or vegetations suggesting endocarditis 1, 5
• Aortic arch atherosclerosis - a cardioaortic source of embolism 1, 3

Additional Structural Abnormalities

• Cardiac tumors (e.g., atrial myxoma) 3, 6
• Spontaneous echo contrast in the left atrium (marker of blood stasis) 4
• Valvular vegetations in suspected endocarditis 5, 6

Algorithmic Approach to Echocardiography Selection

Step 1: Initial Assessment

Start with transthoracic echocardiography (TTE) as the first-line, less invasive test for all patients meeting indications for cardiac evaluation. 1, 2

Step 2: Consider TEE in Specific Situations

Transesophageal echocardiography (TEE), cardiac CT, or cardiac MRI might be reasonable in patients with embolic stroke of undetermined source (ESUS) to identify cardioaortic sources or transcardiac pathways not well-visualized on TTE. 1, 2

TEE is particularly indicated when: 1, 4

• TTE is technically inadequate (poor acoustic window)
• High suspicion for atrial sources (PFO, atrial thrombus, atrial septal abnormalities)
• Evaluation of aortic arch atherosclerosis is needed
• Patient is younger (<45 years) with cryptogenic stroke 4

Step 3: Timing Considerations

Echocardiography should not delay acute stroke management and can typically be performed after initial stabilization and treatment. 2 The diagnostic evaluation should be completed or underway within 48 hours of stroke symptom onset. 1

Critical Pitfalls to Avoid

Do not order routine echocardiography in all stroke patients - studies show that in patients lacking clinical or routine laboratory evidence of heart disease, echocardiography is unlikely to yield findings that alter clinical management. 5 The yield is particularly low in unselected screening. 4

Do not rely solely on M-mode echocardiography - 2D echocardiography is superior for detecting left ventricular thrombus and other structural abnormalities. 5

Do not assume TTE adequately evaluates all potential sources - atrial and aortic sources require TEE for optimal visualization. 1

During TEE, monitor patients closely and position appropriately to decrease aspiration risk if nausea or vomiting occurs, as these patients may have dysphagia. 1

Prognostic Value

The presence of systolic dysfunction on echocardiography is an independent prognostic variable predicting both short- and long-term cardiac events in stroke patients. 1 This information guides not only secondary stroke prevention but also overall cardiovascular risk management.