Cardiac investigations after ischaemic stroke

Editor – I read with great interest the paper by Helliwell et al.¹ The authors describe the case of a patient with stroke due to cardiac papillary fibroelastoma (CPF) successfully treated with systemic thrombolysis. They discuss two main points: the safety of the reperfusion therapy in stroke due to CPF and the importance of early evaluation with transthoracic echocardiography (TTE) in patients with ischaemic stroke.

In relation to the first point, CPF is a very infrequent cause of stroke. Due to this rarity, (also considering CPF as the cause of 1% of all cardioembolic infarctions, cardioembolic strokes as 30% of all ischemic strokes and eligibility for alteplase of about 8%), the probability for a stroke physician to treat with thrombolysis a patient with stroke due to an unknown CPF would be less than one patient in every 4,000.^2,3 Furthermore, in the cases described in literature, outcome was generally good, without significant increase of intracerebral hemorrhage; unlike myxoma, CPF usually do not cause invasive destruction of the cerebral vasculature, so reducing hemorrhagic risk.³ Hence, neurologists should not fear a CPF as the underlying cause of stroke in the setting of thrombolysis.

As to the importance of early completion of cardiac investigations after ischaemic stroke, current evidence on cost-effectiveness seems insufficient to justify routine use of TTE in all stroke patients.^4,5 The reported yield of TTE ranges from 1.3% to 48.0% with differences mainly due to the used definition of ‘yield’ (any echo abnormality, any potential cardiac source of embolism and major risk sources only).^6,7 In a recent series considering more relevant clinical criteria, TTE might lead to a change in clinical management in ∼1/10 patients, but changed acute treatment decisions in <1% of patients.⁸ The importance of an early TTE investigation is probably not generalisable and dependent on age and vascular risk burden of the patient and on the type of the stroke. Stroke due to CPF are generally embolic stroke of undetermined source in patients under 60 years and often without major vascular risk factors, a subgroup with clear indication to TTE as first-line investigation.