Introduction: In young adult stroke patients, up to 25% meet the embolic stroke of undetermined source (ESUS) criteria. Although the transesophageal echocardiography (TEE) is considered the gold-standard study to exclude some embolic sources, it is not deemed necessary for the ESUS definition. Our aim is to evaluate the diagnostic yield and therapeutic impact of the TEE in young adults with ESUS. Methods: Retrospective analysis of a single-center cohort of consecutive young adult ischemic stroke patients (18-55 years), admitted between 2010-2018, satisfying ESUS criteria. In these patients, TEE findings and consequent diagnostic and therapeutic implications were characterized. The following findings were considered possible stroke etiologies: intracavitary/aortic thrombus, vegetation, patent foramen oval (PFO) with interatrial septum aneurysm (ASIA) and/or large shunt and Risk of Paradoxical Embolism (RoPE) score ≥7, atrial/ventricular septum defect and complex aortic arch atheroma. Results: Among 293 young adult stroke patients, 116 (39.6%) fulfilled the ESUS criteria. 113 (97.4%) underwent TEE, which allowed to disclose the stroke etiology in 32 (28.3%): intracavitary/aortic thrombus in 1.8% (n=2), vegetation in 0.9% (n=1), PFO with ASIA and/or large shunt and RoPE score ≥7 in 19.5% (n=22), atrial/ventricular septum defect in 1,8% (n=2) and complex aortic arch atheroma in 4,4% (n=5). TEE findings modified the secondary prevention strategy in 30.1% (n=34): anticoagulation in 15% (n=17), PFO/septum defect closure in 23% (n=26) and antibiotic treatment in 0.9% (n=1). Conclusion: The diagnostic yield of TEE in young adults with ischemic stroke may question the defined ESUS criteria in this age group.
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