Transcranial Doppler is Complementary to Echocardiography for Detection and Risk Stratification of Patent Foramen Ovale (original) (raw)
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Accuracy of Transcranial Doppler for the Diagnosis of Intracardiac Right-to-Left Shunt
JACC: Cardiovascular Imaging, 2014
The aim of this meta-analysis was to determine the accuracy of transcranial Doppler (TCD) compared with transesophageal echocardiography (TEE) as the reference. B AC K G R O U N D Right-to-left shunting (RLS), usually through a patent foramen ovale (PFO), has been associated with migraine, cryptogenic stroke, and hypoxemia. With emerging observational studies and clinical trials on the subject of PFO, there is a need for accurate diagnosis of PFO in patients with these conditions, and those being considered for transcatheter closure. Although a TEE bubble study is the current standard reference for diagnosing PFO, the TCD bubble study may be a preferable alternative test for RLS because of its high sensitivity and specificity, noninvasive nature, and low cost. M E T H O D S A systematic review of Medline, the Cochrane Library, and Embase was done to look for all the prospective studies assessing intracardiac RLS using TCD compared with TEE as the reference; both tests were performed with a contrast agent and a maneuver to provoke RLS in all studies. R E S U LT S A total of 27 studies (29 comparisons) with 1,968 patients (mean age 47.8 AE 5.7 years; 51% male) fulfilled the inclusion criteria. The weighted mean sensitivity and specificity for TCD were 97% and 93%, respectively. Likewise, the positive and negative likelihood ratios were 13.51 and 0.04, respectively. When 10 microbubbles was used as the embolic cutoff for a positive TCD study, TCD produced a higher specificity compared with when 1 microbubble was used as the cutoff (p ¼ 0.04); there was, however, no significant change in sensitivity (p ¼ 0.29). C O N C L U S I O N S TCD is a reliable, noninvasive test with excellent diagnostic accuracies, making it a proficient test for detecting RLS. TCD can be used as a part of the stroke workup and for patients being considered for PFO closure. If knowledge of the precise anatomy is required, then TEE can be obtained before scheduling a patient for transcatheter PFO closure.
Stroke, 2004
Background and Purpose-Transcatheter closure of patent foramen ovale (PFO) is increasingly being performed and monitored with transthoracic or transesophageal echocardiography, whereas contrast-enhanced transcranial Doppler (ce-TCD), which probably represents the most suitable tool to quantify right-to-left shunt (RLS) in the brain vessels, has been systematically overlooked. Our goal is to prospectively assess efficacy and safety of PFO transcatheter closure using ce-TCD. Methods-A total of 140 consecutive patients (mean age, 46Ϯ13 years; male/female ratio, 63/77) with PFO-related large RLS and no other recognized cause of focal cerebral ischemia underwent transcatheter closure. TCD was done preoperatively and 1 month after the procedure in all patients, after 3 months in 120, after 6 months in 112, and after 1 year in 104 patients. Results-Implantation was successful in all patients. During Valsalva strain, a large shunt was still detectable in 31 of 140 (22%), 15 of 120 (13%), 9 of 112 (8%), and 9 of 104 (9%) patients at the 1-, 3-, 6-, and 12-month visits, respectively. Periprocedural and postprocedural complications included atrial fibrillation in 8% and scintillating scotomata in 6% of patients. During the 1-year follow-up period, only 1 transient ischemic attack was recorded in a patient with paroxysmal atrial fibrillation and complete PFO closure. Conclusions-Transcatheter PFO closure in patients with cryptogenic stroke and large RLS may be less successful than reported previously. TCD appears the ideal tool to follow up the closure process and to identify early, during follow-up, those patients who will be left with a significant shunt. Atrial fibrillation is more common than believed previously and may underlie the occurrence of further cerebrovascular events despite complete PFO closure. Irritative visual phenomena may occur as a consequence of nickel toxicity. (Stroke. 2004;35:2140-2144.)
Arquivos de Neuro-Psiquiatria, 2008
Right-to-left shunt (RLS) can be identified by contrast-enhanced transcranial Doppler (cTCD) in patent foramen ovale (PFO) patients. AIM: To evaluate cTCD for PFO screening comparing it to cTEE. METHOD: 45 previous cTCD performed for PFO diagnosis and correlated its findings with cTEE. Patients were submitted to a cTCD standardized technique and were divided in two groups according to RLS: Group 1, patients with a positive RLS and Group 2 when RLS was negative. RESULTS: 29 (65%) patients were included in group 1 and 16 (35%) in group 2. PFO confirmation by cTEE was performed in 28 (62%) patients. cTCD had a 92.85% sensitivity, 82.35% specificity, 89.65% positive predictive value and 87.5% negative predictive value when compared to cTEE for PFO diagnosis. CONCLUSION: Standardized technique cTCD allows for RLS visualization in PFO patients with a good correlation with cTEE and can be used as a screening test before cTEE.
ROLE OF TRANSCRANIAL DOPPLER FOR ASSESSMENT OF PERSISTENT FORAMEN OVALE IN PATIENTS WITH STROKE
Knowledge International Journal, 30(4), 757 - 759., 2019
Transcranial Doppler (TCD) is a noninvasive, portable easy-to perform and easy to interprettechnique for evaluating the intracranial vasculature. The indications for a TCD ultrasound examination of adults include detection of right-to-left shunts (RLS)..The prevalence of a patent foramen ovale (PFO) in the general population is ≈25-30%. Thrombus, formed in the venous systemcould cross the interatrial septum via PFO and provoke paradoxical embolism. The aim of our study was to select those patients, diagnosed with embolic stroke with undetermined etiology (ESUS), who are at higher risk for paradoxical embolism. Materials and methods: During one year a total of 21 consecutive patients (14 male and 7 female) with ESUS were directed to cardiology department for further evaluation. They underwent cTCD for detection of RLS. Results: In part of the patients another risk factors were found. The most commonly encountered stroke was in vertebro-basilar system and in left middle cerebral artery territory. RLS was detected in 12 patients-3 females and 9 males. The medium RoPE score in patients with significant RLS was 6.5. Four patients with RoPE score ≥ 8 were scheduled for PFO closure and the procedure was performed without any complications. Conclusion: TCD is a reliable non-invasive technique to identify ESUS patients with risk for paradoxical embolism. Keywords: Transcranial Doppler, patient foramen ovale, stroke INTRODUCTION Ischemic stroke occurs as a result of obstruction of the brain arteries. Approximately 25% of all ischemic strokes are of undetermined etiology [1]. They are classified as embolic stroke with unknown source (ESUS). The potential embolic sources include those with minor risk as mitral and aortic valve calcification, covert atrial fibrillation, cancer-associated, atherogenic emboli and paradoxical embolism, mostly by PFO [2]. Paradoxical embolism is identified as a cause 4,5-5% of strokes [3,4]. The most common reason for RLS is the patient foramen ovale.The prevalence of a patent foramen ovale (PFO) in the general population is ≈25-30% [5,6]. The vast majority of these people have no problems, due to this condition. Rarely thrombus, formed in the venous system or the right atrium could cross the interatrial septum via PFO and provoke paradoxical embolism-stroke or peripheral embolization [7]. The proven methods to detect RLS are contrast transthoracic echocardiography (c-TTE), contrast transesophageal echocardiography (c-TTE) and contrast transcranial Doppler ultrasonography (c-TCD) (al, 2002). Transcranial Doppler (TCD) is a noninvasive, portable technique for evaluating the intracranial vasculature. The latter is easy-to perform and easy to interpret, low-cost technique, which allows a semiquantitative estimation of venous-to arterial circulation shunts.The data for efficacy of PFO closure for stroke prevention has been uncertain.The randomized clinical trials (RCTs) before 2017 failed to demonstrate that the closure of PFO reduces the risk of subsequent stroke [10-12].Two new trials, published in 2017 [13,14], one in 2018 [15] and one follow-up [16] proved that PFO closure was superior to medical therapy in stroke prevention [17]. The aim of our study was to select those patients, diagnosed with embolic stroke with undetermined etiology (ESUS), who are at risk for paradoxical embolism.
Journal of Stroke and Cerebrovascular Diseases, 2009
Background: Patent foramen ovale (PFO) has been investigated in several conditions apart from cryptogenic ischemic stroke. Contrast transesophageal echocardiography (cTEE) is the gold standard for the diagnosis, although it has some known limitations. Contrast transcranial Doppler (cTCD) allows a semiquantitative estimation of right-toleft shunt (RLS) volume. The aims of our study were to confirm the diagnostic accuracy of cTCD in PFO diagnosis and to compare the abilities of cTCD and cTEE to detect a RLS and PFO, respectively, under normal breathing. The latter could represent an important feature for its clinical significance. Methods: A total of 100 consecutive patients (59 women and 41 men, age 46 6 12 years) were evaluated after stabilized ischemic stroke/transient ischemic attack, migraine, and lacunae, and before neurosurgery in sitting position. All patients undertook cTEE and cTCD, at rest and under Valsalva maneuver (VM). cTEE under VM was the reference standard. A categorization of patients and a semiquantitative cTCD classification were proposed. Results: In all, 63 of 100 patients had PFO diagnosed by cTEE. A general concordance of up to 90% between both techniques was found. cTCD sensitivity and specificity were 96.8% and 78.4%, respectively. In 17 of 100 patients with cTEE-proven PFO under VM, cTCD and cTEE detected RLS at rest in 75% (95% confidence interval [CI] 62%-85%) and 48% (95% CI 35%-61%) of cases, respectively (P , .001). cTEE disclosed RLS at rest in about 71% (95% CI 9%-42%) of cTCDs showing a ''shower-curtain'' pattern and only in about 22% (95% CI 52%-85%) of those cTCDs without that pattern. Conclusions: In diagnosing PFO, cTCD has a good accuracy compared with cTEE. To detect a RLS at rest, cTCD appears to be more sensitive than cTEE. The latter resulted positive under normal breathing, mostly in cases of significant RLS at cTCD. Our results point out the impact of cTCD in the evaluation of RLS volume, thus aiding, in association with the anatomic details by cTEE, in the prevention of the occurrence or recurrence of paradoxical embolism in individuals with and without cerebrovascular diseases. The combination of cTEE and cTCD could be considered the real gold standard for PFO in the near future.
Journal of Neuroimaging, 2006
Background and Purpose. Transesophageal echocardiography (TEE) and transcranial Doppler (TCD) are the methods of choice to study patent foramen ovale (PFO), but there are discrepancies between the 2 concerning PFO detection. No study has analyzed right-to-left shunt (RLS) quantification concordance. The 2 methods are carried out in different hemodynamic states, and the Valsalva maneuver (VM) required in each also differs. The authors compared PFO detection and concordance of RLS quantification classifications performing the 2 studies simultaneously. Methods. The authors prospectively included consecutive stroke patients undergoing TEE and applied the TCD protocol of the Consensus Conference. Echocardiographic PFO was diagnosed when at least 3 microbubbles (MBs) were detected in the left atrium within 3 heartbeats after opacification of the right atrium. RLS quantification was (1) TCD: minimum (1-10 MBs), moderate (11-25 MBs), and massive (>25 MBs) and (2) TEE: small (3-10 MBs), moderate (11-30 MBs), and large (>30 MBs). Statistics: contingency tables (χ 2 and K test). Results. The authors studied 110 patients whose mean age was 56.7 ± 12.1 years, and 60.9% were men. PFO was detected at the first VM in 30% of patients with TCD and in 31.8% with TEE. At the second VM, both methods detected the same patients (32.7%). RLS was minimum (14), moderate (5), and massive in TCD and small (13), moderate (3), and large (20) in TEE. There was an almost perfect concordance in RLS quantification (K = 0.928, P = .001), with only 4 discrepancies.
International Journal of Cardiology, 2011
Contrast transthoracic echocardiography (c-TTE) [1,2] and contrast transcranial Doppler (c-TCD) [3,4] are widely used for noninvasive diagnosis of patent foramen ovale (PFO). We thought to evaluate in a large series of patients the concordance between c-TTE and c-TCD in right-to-left shunt (RLS) diagnosis and in quantification. From June 2006 to July 2009 RLS was looked for in two hundred thirty two consecutive patients (160 females, aged 42.6 ± 15.3 years) who underwent on succession c-TCD and c-TTE at echocardiography laboratories of San Paolo and Dell'Angelo Hospitals (Milano and Mestre-Venezia, Italy). All patients gave their informed consent. The reason for RLS search was migraine in 167 patients (72%), stroke in 23 patients (9.9%), TIA in 29 patients (12.5%) and other causes in 13 patients (5.6%). Contrast TTE and TCD tests were performed using an agitated saline solution mixed with air [4]. Given that the Valsalva maneuver (VM) increases the sensitivity of RLS detection all patients were trained in VM execution. In all cases the study begun with c-TCD. In case of no or little microbubbles (MB) detection at the MCA the test was repeated with VM. Results were classified in a four-level categorization according to MB appearance in the TCD spectrum as follows: 0 indicates no occurrence of MB (test negative), 1 indicates 1-10 MB (small shunt), 2 indicates N 10 MB without "curtain" effect (medium shunt) and finally 3 indicates "curtain" effect, whereas MB are so numerous that a single MB cannot be discriminated within the Doppler spectrum (large shunt) [4]. Subsequently patients underwent c-TTE. Once again results were classified in a four-level categorization according to MB appearance in the left hear after complete opacification of the right atrium [2]: 0 indicates no occurrence of MB (test negative), 1 indicates b 10 MB passed through the PFO (small shunt), 2 indicates a cloud of N 10 MB documented in the left atrium (medium shunt) and 3 indicates opacification of the left heart (large shunt) [5]. Quantitative data were expressed as mean ± standard deviation. Inter observer agreement in the diagnosis and grading of RLS both on c-TCD and c-TTE was assessed by calculating the Kappastatistic. Odds Ratios and 95% Confidence Intervals were calculated. The concordance between c-TCD and c-TTE scores was estimated using the Lin's concordance correlation coefficient and the Spearman's rho rank correlation coefficient. Finally, the optimal trade-off between sensitivity and specificity of c-TTE was estimated by means of Receiver Operating Characteristic (ROC) curve analysis. All calculations were repeated on split subgroups with homogeneous diagnostic question. Overall, we noticed an excellent interobserver agreement both in c-TCD RLS scoring (K = 0.962, 95%CI 0.93-0.99) and in c-TTE RLS scoring (K = 0.985, 95%CI 0.96-1.00). Subsequently, we compared the c-TCD and c-TTE RLS gradations. In the overall study population the concordance correlation coefficient (CCC) between c-TCD and c-TTE RLS scores was CCC = 0.68 (95%CI 0.60-0.74), indicating a moderate correlation between c-TTE and c-TCD. The Spearman's coefficient of rank correlation (rho) was 0.68 (95%CI 0.60-0.74) confirming a moderate correlation between the two diagnostic procedures. Correlation and concordance between c-TCD and c-TTE RLS gradations were then analyzed in two subgroups of patients with homogeneous diagnostic question. The CCC between c-TCD and c-TTE RLS scores was moderate in patients with migraine (CCC = 0.63, 95%CI 0.53-0.71), and was good in patients referred for cerebrovascular diseases (CVD) (CCC = 0.87, 95%CI 0.79-0.92). The Spearman's coefficient of rank correlation was 0.63 (95% CI 0.52 -0.71) in patients with migraine and 0.88 (95%CI 0.80-0.93) in patients with CVD, confirming the good correlation between the two diagnostic procedures in this subgroup of patients. The diagnostic performance of c-TTE compared with the presence of MB on c-TCD is exhibited by the Receiver Operating Characteristic (ROC) curve . RLS score ≥ 1 on c-TTE can predict the presence of MB on c-TCD with the highest trade-off between sensitivity and specificity both in CVD and in migraine. Nevertheless, in CVD patients c-TTE had a higher sensitivity (100.0; 95% CI 88.1-100.0) and specificity (73.9; 95% CI 51.6-89.8) than in patients with
JACC: Cardiovascular Imaging, 2010
The purpose of this study was to understand the reason for variation in the sensitivity of different methods of detecting right-to-left shunts (RLS). B A C K G R O U N D Patent foramen ovale (PFO) is implicated in the pathogenesis of cryptogenic stroke, decompression illness, and migraine headaches. Intravenous agitated saline injections with tomographic imaging (transthoracic, transesophageal, and intracardiac echocardiography) has been used for detecting intracardiac shunts. Some patients with a high clinical suspicion of PFO have inconclusive echocardiographic study results. Transcranial Doppler (TCD) is an alternative method for detecting RLS that is not dependent on tomographic imaging.
Permanent Right-to-Left Shunt Is the Key Factor in Managing Patent Foramen Ovale
Journal of the American College of Cardiology, 2011
We sought to prospectively evaluate risk of stroke and impact of transcatheter patent foramen ovale (PFO) closure in patients with permanent right-to left shunt compared with those with Valsalva maneuver-induced right-toleft shunt. Background Pathophysiology and properly management of PFO still remain far from being fully clarified: in particular, the contribution of permanent right-to-left shunt remains unknown. Methods Between March 2006 and October 2010, we enrolled 180 (mean age 44 Ϯ 10.9 years, 98 women) of 320 consecutive patients referred to our center for transcatheter PFO closure, who had spontaneous permanent right-toleft shunt on transcranial Doppler and transthoracic/transesophageal echocardiography. All patients fulfilled the standard current indications for transcatheter closure and underwent preoperative transesophageal echocardiography and brain magnetic resonance imaging, with subsequent intracardiac echocardiographic-guided transcatheter PFO closure. We compared the clinical echocardiographic characteristics of these patients (Permanent Group) with the rest of 140 patients with right-to-left shunt only during Valsalva maneuver (Valsalva Group). Results Compared with the Valsalva Group patients, patients of the Permanent Group had increased frequency of multiple ischemic brain lesions on magnetic resonance imaging, previous recurrent stroke, previous peripheral arteries embolism, migraine with aura, and-more frequently-atrial septal aneurysm and prominent Eustachian valve. The presence of permanent shunt confers the highest risk of recurrent stroke (odds ratio: 5.9, 95% confidence interval: 2.0 to 12, p Ͻ 0.001). No differences were recorded between the 2 groups with regard to recurrence of ischemic events after the closure procedure. Conclusions Despite its small-sample nature, our study suggests that patients with permanent right-to-left shunt have potentially a higher risk of paradoxical embolism compared with those without.