Expert opinion paper on cardiac imaging after ischemic stroke

Figures

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  Fig. 1. Scheme of the different topographies of the ultrasound probes and example imaging planes to illustrate differences in the ability to visualize cardiac structures, modified from [35, 36]. Common potential sources of embolism (high risk—blue, minor/unclear—green) or indicators of cardiovascular disease (black) are shown. Further, less common potential sources of embolism and echocardiographic findings are provided in Table 1

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  Fig. 2. Image acquisition transthoracic echocardiography protocol in post-stroke patients. Parasternal long axis view for measurements of left ventricular (LV) diameters, left ventricular outflow tract (LVOT) diameter, LV-wall thickness, dimensions of the aortic arch (a); parasternal short axis view at the level of the mitral valve (MV) for assessment of MV pathologies, detection or exclusion of MV stenosis or MV regurgitation (b); parasternal short axis view at the level of the aortic valve (AV) for assessment of AV pathologies, detection or exclusion of AV stenosis or AV regurgitation (c); parasternal short axis view at the level of the pulmonary valve (PV) and pulsed wave (pw) Doppler spectrum of the right ventricular (RV) outflow tract (RVOT) flow to assess RV stroke volume for pulmonary stroke volume (Qp)/ systemic stroke volume (Qs)—calculation (d); parasternal short axis view of the interatrial septum to detect or exclude atrial communication defects (e); apical long axis view for assessment of LV function using deformation imaging (f); color-coded apical long axis view for assessment of AV function including pw Doppler spectrum of the LVOT flow to assess LV stroke volume for…

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  Fig. 3. Image acquisition transoesophageal echocardiography protocol in post-stroke patients. Midoesophageal 4-chamber view for assessment of LV function using deformation imaging, if documentation using transthoracic echocardiography (TTE) is not possible (a); midoesophageal 2-chamber view for assessment of LV function using deformation imaging, if TTE documentation is not possible (b); midoesophageal long-axis view for assessment of LV function using deformation imaging, if TTE documentation is not possible (c); conventional 2D-documentation at least in 2 different sectional planes of the interatrial septum (IAS) (d); color-coded 2D-documentation at least in 2 different sectional planes of the IAS to document interatrial communication defects (e); contrast 2D-documentation with agitated saline at least in 2 different sectional planes of the IAS to document patent foramen ovale (PFO). Ideally no or mild sedation of the patient is performed and the Valsalva maneuver practiced with the patient before administration of agitated saline contrast agent. If available, 3D transoesophageal probes should be used and the test repeated several times, if negative. Good documentation is necessary to…

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  Fig. 4. Expert-based recommendations for post-stroke imaging. Patients with (acute) ischemic stroke or TIA should receive transthoracic echocardiography (TTE) if either a cardiac cause of stroke is suspected or any cardiovascular risk factor is present. Transoesophageal echocardiography (TOE) should additionally be performed in patients with suspicious findings, insufficient image quality or if no cardiac source of stroke was detected despite clinical suspicion for cardioembolic stroke (†TTE and TOE in a single session is recommended if the cardiac source of stroke is suspected as indicated by the bold arrow). Inconclusive TTE or TOE and specific suspicion of cardiac disease may lead to further diagnostic work-up, e.g., contrast-enhanced echocardiography or cardiac magnetic resonance imaging. The value of different cardiovascular imaging methods for common cardiac pathologies is listed in Table 1