Is an echocardiogram (echo) necessary for patients presenting with stroke-like symptoms, particularly those with a history of cardiovascular disease, atrial fibrillation, or other conditions that increase the risk of cardiac embolism?

Echocardiography for Stroke-Like Symptoms

Echocardiography should be performed selectively in patients with stroke-like symptoms, not routinely in all cases, with the decision based on specific clinical indicators including age, presence of cryptogenic stroke, suspected cardiac disease, and absence of clear vascular etiology. 1, 2

When Echocardiography IS Indicated

Strong Indications

• Cryptogenic stroke or embolic stroke of undetermined source (ESUS), particularly when neurovascular imaging shows no clear vascular cause 1, 2
• Young adults (age <50 years) presenting with stroke or TIA of unknown etiology—the diagnostic yield is substantially higher with a number needed to test of only 6 patients to detect one cardiac source of embolism 3
• Clinical or laboratory evidence of underlying heart disease, including suspected infectious endocarditis, known atrial fibrillation, or heart failure 1, 2
• History of coronary artery disease combined with acute infarction on MRI—this combination yields a 29% detection rate for cardiac sources of embolism 4

Algorithmic Approach by Age

• Age <50 years: Echocardiography should be performed routinely due to high diagnostic yield 3
• Age 50-70 years: Perform echocardiography if cryptogenic stroke, cardiac disease suspected, or acute infarction on MRI 3, 4
• Age >70 years: Use highly selective approach—number needed to test increases to 62 patients, resulting in high rates of nonspecific findings 3

Choosing Between TTE and TEE

Start with Transthoracic Echocardiography (TTE)

• TTE is the recommended first-line test for all patients meeting indications for cardiac evaluation 1, 2
• TTE effectively identifies ventricular sources including left ventricular thrombus, dyskinetic wall segments, regional wall motion abnormalities, and global LV systolic dysfunction 1
• Moderate to severe LV systolic dysfunction on TTE is the only independent echocardiographic predictor of stroke after adjusting for clinical features 5

Upgrade to Transesophageal Echocardiography (TEE)

• TEE is superior for atrial and aortic arch sources and should be considered when TTE is nondiagnostic in cryptogenic stroke 1, 6
• TEE detects patent foramen ovale, atrial septal defects, left atrial/left atrial appendage thrombus, and aortic arch atherosclerosis far better than TTE 1, 6
• In one study, TEE identified potential cardiac sources in 57% of patients with unexplained stroke versus only 15% for TTE 6
• TEE is particularly valuable in patients with clinically identified cardiac disease—all cases of left atrial thrombus or spontaneous contrast were found in this subgroup 6

When Echocardiography Is NOT Routinely Indicated

Low-Yield Scenarios

• Older patients (>70 years) without clinical cardiac disease—routine screening results in high rates of nonspecific findings with minimal impact on management 3
• Patients lacking clinical or routine laboratory evidence of heart disease—in one study of 47 such patients, echocardiography identified no potential embolic sources that altered therapy 7
• Clear non-cardiac stroke etiology identified (e.g., large vessel atherosclerosis, small vessel disease with typical lacunar syndrome) 2

Important Caveat About Atrial Fibrillation

While echocardiography is valuable for defining the origin of AF and may add information for risk stratification, echocardiographic findings have limited value as the prime determinant for chronic anticoagulation decisions in AF patients 5. Clinical risk factors (prior stroke/TIA, age, hypertension, diabetes, heart failure) are the dominant factors for stroke risk stratification, not echocardiographic parameters 5.

Clinical Timing and Practical Considerations

Timing Relative to Acute Management

• Echocardiography should not delay acute stroke treatment including thrombolytic therapy or mechanical thrombectomy 2
• Brain imaging (non-contrast CT) must be prioritized and performed within 30 minutes of admission 2
• Echocardiography can typically be performed after initial stabilization and acute treatment 2

Impact on Management

• Changes in antithrombotic therapy resulting from echocardiography occur in only 2.5-10% of patients 4
• The most common cardiac sources identified include atrial fibrillation (7%), patent foramen ovale (6%), complex aortic arch atherosclerosis, and left ventricular thrombus 3, 4
• Presence of systolic dysfunction on echocardiography serves as an independent prognostic variable predicting both short- and long-term cardiac events, guiding secondary prevention 1

Common Pitfalls to Avoid

• Do not order routine echocardiography in elderly patients without cardiac disease—this leads to resource waste and nonspecific findings 3
• Do not rely on TTE alone for cryptogenic stroke in younger patients—TEE may be necessary to identify atrial sources 1, 6
• Do not use echocardiographic findings as the sole basis for anticoagulation decisions in AF—clinical risk scores should guide this decision 5
• Do not delay acute stroke treatment to obtain echocardiography—cardiac evaluation is part of secondary prevention, not hyperacute management 2