Intracranial embolism characteristics in PFO patients: A comparison between positive and negative PFO by transesophageal echocardiography The rule of nine (original) (raw)
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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.
Objective: Patent foramen ovale (PFO) can be detected in up to 43% of patients with cryptogenic cerebral ischemia undergoing investigation with transesophageal echocardiography (TEE). The diagnostic value of transthoracic echocardiography (TTE) in the detection of PFO in patients with cryptogenic ischemic stroke (IS) or transient ischemic attack (TIA) has not been compared with that of transcranial Doppler (TCD) using a comprehensive meta-analytical approach. Methods: We performed a systematic literature review to identify all prospective observational studies of patients with cryptogenic cerebral ischemia that provided both sensitivity and specificity measures of TTE, TCD or both compared to the gold standard of TEE. Results: Our literature search identified 35 eligible studies including 3067 patients. The pooled sensitivity and specificity for TCD was 96.1% (95% confidence interval: 93.0%-97.8%) and 92.4% (95%CI: 85.5%-96.1%), whereas the respective measures for TTE were 45.1% (95%CI: 30.8-60.3%) and 99.6% (95%CI: 96.5-99.9%). TTE was superior in terms of higher positive likelihood ratio values (LR+= 106.61, 95%CI: 15.09-753.30 for TTE vs. LR+=12.62, 95%CI: 6.52-24.43 for TCD; p=0.043), while TCD demonstrated lower negative likelihood values (LR-= 0.04, 95%CI: 0.02-0.08) compared to TTE (LR-=0.55, 95%CI: 0.42-0.72; p<0.001). Finally, the area under the summary receiver operating curve was significantly greater (p<0.001) in TCD (AUC=0.98, 95%CI: 0.97-0.99) compared to TTE studies (AUC=0.86, 95%CI: 0.82-0.89).
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
Patent Foramen Ovale: Paradoxical Embolism and Paradoxical Data
Mayo Clinic Proceedings, 2004
related to the diagnosis and treatment of patients with cerebral infarction and PFO. These articles are timely because of the considerable interest, within the cardiology community, in the importance of PFO. Some cardiologists estimate that 60,000 to 110,000 strokes are secondary to paradoxical embolism via a PFO. 16,17 Besides preventing stroke, transcatheter closure of PFO has been proposed as a prophylactic treatment for migraine headache. 18 However, questions persist. Much of the current evidence is circumstantial or anecdotal. Reports about the potential utility of medical or surgical interventions are from uncontrolled studies, which can be biased. When the rules of evidence are used, these studies provide data of modest strength. Of note, evidence from prospective clinical studies has not matched our preconceived notions. 19,20 Specifically, the risk of stroke might not be as high as previously believed, and relatively conservative medical therapies might be effective. Because of reservations about the robustness of the current data, many neurologists are uncertain about the cause-and-effect relationship between PFO and stroke and about the best management of patients. See also pages 24, 35, and 79. This commentary poses a series of questions and includes currently available data; it also serves as a springboard for further discussions. What Is the Association Between PFO and Cerebral Infarction? Depending on the criteria used for diagnosis and the technology used in cardiac assessment, the prevalence of PFO in the healthy population is approximately 20% to 25%. 16,21,22 On the basis of this prevalence, we can estimate that approximately 60 million to 70 million Americans have a PFO. Thus, detection of a PFO during the evaluation of a patient with stroke is not surprising, and the frequency
Size of PFO and amount of microembolic signals in patients with ischaemic stroke or TIA
European Journal of Neurology, 2008
Background and purpose: The inter-relation between the size of patent foramen ovale (PFO) by transesophageal echocardiography (TEE) and the amount of microembolic signals (MES) on transcranial doppler (TCD) is still not determined. Methods: The study group comprised of 104 patients with first-ever ischaemic stroke or transient ischemic attack (TIA). Three groups were formed according to the amount of MES on TCD: a small amount of MES (0-10 MES); a moderate amount of MES (countable MES higher than 10); and multiple MES. Results: According to TEE, there were 52 patients (50%) with a small PFO, 37 patients (35.6%) with a moderate PFO, and 15 patients (14.4%) with a large PFO. There were 48 patients (46.1%) with a small amount of MES, 34 patients (32.7%) with a moderate amount of MES, and 22 patients (21.1%) with multiple MES on TCD. A strong relationship between the size of the PFO on TEE and the amount of MES on contrast transcranial Doppler was found (P < 0.0001), such that the larger the PFO on TEE, the greater the amount of MES on TCD. Conclusions: There is a high correlation between the size of the PFO on TEE and the amount of MES on TCD in stroke and TIA patients.
Canadian Journal of Cardiology, 2016
Background: In patients with patent foramen ovale (PFO), strategies are needed to identify patients at higher risk, who might benefit from PFO closure. Methods: We studied the frequency of detection of a Right-Left Shunt (RLS) by trans-esophageal echocardiography (TEE) among patients with cryptogenic stroke and transcranial Doppler (TCD) RLS, and analyzed the prediction of recurrent stroke by TCD shunt grade, by detection of RLS on TEE, and by atrial septal aneurysm or mobility. Results: Among 334 patients with TCD, 69.8% female, mean (SD) age 53 (14) years, with a median followup of 420 days, there were 284 cases with both TCD and TEE; 54 (19%) had atrial septal aneurysm or mobility. Echocardiography failed to show a RLS in 43 (15.1%) of the patients who had both TCD and TEE, even in some patients with high-grade shunts on TCD: 18 (42%) were grade 3 or higher on TCD. Survival free of stroke or TIA was predicted significantly by TCD shunt grade < 2 (p=0.028), shunt grade < 3 (p=0.03), and shunt grade < 4 (p<0.0001); this was attenuated by adjustment for risk factors in Cox regression (p= 0.08) Neither RLS on TEE (p=0.47), or atrial septal aneurysm or mobility (p=0.08), predicted events. Conclusions: Our findings suggest that TCD may be more sensitive than TEE for detection of RLS, which misses some cases with substantial right to left shunts, and may be valuable for prediction of recurrent stroke/TIA in patients with PFO. TCD complements TEE for management of suspected paradoxical embolism.
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.
Neurological Sciences, 2020
Backgroud The role of patent foramen ovale (PFO) in cryptogenic stroke (CS) is debated. Tools to predict PFO occurrence and attributable fraction are needed to guide cost-effective diagnostics and treatment. Risk of Paradoxical Embolism (RoPE) score relies on neuroimaging findings, which might be inconclusive in up to 30% of cases. Methods We developed a clinical-based easy tool to predict the presence and attributable fraction of PFO in CS patients, without using neuroimaging. The clinical RoPE (cRoPE) score, ranging 1-10, was elaborated through Delphi method from the original RoPE score, replacing cortical infarction with the Oxfordshire Community Stroke Project (OCSP) classification (lacunar stroke = 0 points, other subtypes = 1 point). Then, from the SISIFO (Studio Italiano di prevalenza nello Stroke Ischemico di pervietà del Forame Ovale, or Prevalence of Patent Foramen Ovale in Ischemic Stroke in Italy) study, a multicenter, prospective study on consecutive acute ischemic stroke patients (n = 1130) classified by Trial of Org 10172 in Acute Stroke Treatment (TOAST) and OCSP criteria and undergoing PFO testing, we selected the VV-CDC cohort (Vibo Valentia, Città di Castello, n = 323) to test the accuracy of cRoPE in predicting PFO detection. We compared cRoPE with RoPE to verify cRoPE reliability. Finally, we tested, through ROC analysis, the performance of cRoPE depending on TOAST classification. Results Overall, PFO was detected in 21% in VV-CDC and in 23.4% in remaining SISIFO cohort (n = 807). cRoPE AUC and RoPE AUC were similar in VV-CDC. cRoPE performance was comparable with RoPE among CS (cRoPE AUC 0.76, 95%CI 0.67-0.85, RoPE AUC 0.75, 95%CI 0.66-0.84). Moving to the remaining SISIFO cohort, cRoPE confirmed satisfactory accuracy in predicting PFO detection in CS patients (cRoPE AUC 0.71, 95%CI 0.66-0.78, p = 0.032). Conclusions Conclusions: cRoPE might help in stratification of patients with CS, allowing accurate esteem of the likelihood of PFO to be found, especially in cases when neuroimaging is inconclusive.