Relation of transesophageal echocardiographic findings to subtypes of cerebral infarction in patients with atrial fibrillation

Background: Transesophageal echocardiography (TEE) has been used to identify the potential risk for cardiogenic embolism in patients with atrial fibrillation (AF). However, ischemic stroke in patients with AF is not always attributable to embolism. Identification of the risk of embolic versus athero-thrombotic stroke should lead to the optimal individualized management of patients with AF. Hypothesis: The goal of the study was to determine the relation between cortical infarction and perforating infarction and TEE findings in patients with AF. Methods: We investigated the clinical usefulness of TEE in the risk stratification of clinical subtyping of the cerebral infarctions which were divided into two territories of the cortical branch (cortical infarction due to embolism) and deep perforators (perforating infarction due to atherothrombosis). Left atrial spontaneous echo contrast, peak flow velocity in the left atrial appendage, and generalized atherosclerosis as estimated by the intima-media wall thickness of the thoracic aorta were assessed by TEE in 118 consecutive patients with either paroxysmal (n = 44) or chronic (n = 74) AF. All patients underwent either brain computed tomography or magnetic resonance imaging. Results: Cortical and perforating infarction was found in 39 and 18% of patients, respectively. The grade of spontaneous echo contrast was higher in patients with than in those without cortical infarction (p<0.05). In contrast, patients with perforating infarction showed significant increase in the aortic wall thickness when compared with patients without perforating infarction (p <0.05). In addition, multivariate logistic analysis revealed that spontaneous echo contrast was an independent predictor of cortical infarction, while intima-media wall thickness of the aorta, hypertension, and age were useful in predicting the risk of perforating infarction. Conclusions: Transesophageal echocardiography has a potential role in the risk stratification for cortical and perforating infarction in patients with AF.