A comparison of contrast transthoracic echocardiography and contrast transcranial Doppler in cryptogenic stroke patients with patent foramen ovale

The aim of this study was to investigate the prevalence of patent foramen ovale (PFO) in a consecutive unselected cohort of migraine patients (with and without aura) and compare it with a group of ischaemic young and elderly stroke patients. One hundred and forty-one migraine patients were compared with 330 stroke patients (130 young patients; 200 elderly patients) selected from our hospital stroke data bank. PFO was assessed with transcranial Doppler sonography with i.v. injection of agitated saline. The prevalence of PFO was 51.7± in migraine with aura (MA) patients, 33.7± in migraine without aura (MoA) patients, 33.8± in young stroke patients and 20.5± in elderly stroke patients ( P < 0.001). The prevalence of PFO in cryptogenic stroke in young and elderly stroke patients was, respectively, 41.1± and 25± ( P = 0.04). The difference between MA and MoA patients was significant (odds ratio = 2.1). The prevalence of PFO in MA patients is higher than in MoA patients and in young cryptogenic stroke patients.

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Comparison of Transthoracic Echocardiography, Transesophageal Echocardiography, and Transcranial Doppler in the Detection of Patent Foramen Ovale as the Etiology for Cryptogenic Stroke

Journal of Diagnostic Medical Sonography ◽

10.1177/8756479318816983 ◽

2018 ◽

Vol 35 (2) ◽

pp. 127-133

Author(s):

Madison B. Stafford ◽

Jennifer E. Bagley ◽

Dora DiGiacinto

Keyword(s):

Transesophageal Echocardiography ◽

Transcranial Doppler ◽

Transthoracic Echocardiography ◽

Gold Standard ◽

Patent Foramen Ovale ◽

Doppler Sonography ◽

Cryptogenic Stroke ◽

Transcranial Doppler Sonography ◽

Young Patients ◽

Foramen Ovale

The correlation between cryptogenic stroke and patent foramen ovale is high in young patients. Currently, transesophageal echocardiography is the gold standard for detection. However, it is invasive and limits Valsalva maneuvers. This article reviews the diagnostic accuracy of the three modalities: transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler. The results suggest that transcranial Doppler sonography is an accurate, easily accessible procedure for detecting patent foramen ovale and should be considered an excellent alternative to transthoracic or transesophageal echocardiography. Transesophageal echocardiography is still necessary for patients who require treatment. The combination of transcranial Doppler and transesophageal echocardiography provides the highest level of information regarding the complete diagnosis of patent foramen ovales.

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The Efficacy of Contrast Transthoracic Echocardiography and Contrast Transcranial Doppler for the Detection of Patent Foramen Ovale Related to Cryptogenic Stroke

BioMed Research International ◽

10.1155/2020/1513409 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Jing Yang ◽

Huiqin Zhang ◽

Yumeng Wang ◽

Shiquan Zhang ◽

Tingyu Lan ◽

...

Keyword(s):

Likelihood Ratio ◽

Transcranial Doppler ◽

Transthoracic Echocardiography ◽

Gold Standard ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Negative Likelihood Ratio ◽

Foramen Ovale ◽

Sensitivity Specificity ◽

Grade Iii

Background. Patent foramen ovale (PFO) has been linked to the pathophysiology of cryptogenic stroke. Contrast transesophageal echocardiography (cTEE) is the current gold standard for PFO diagnosis, but it has the disadvantage of being semi-invasive and does not exempt from risks. As a diagnostic test, the efficacy of contrast transthoracic echocardiography (cTTE) and contrast transcranial Doppler (cTCD) is controversial. This study is aimed at investigating the efficacy of cTTE and cTCD versus cTEE in PFO detection, exploring a more cost-effective and reliable method for the diagnosis of PFO related to cryptogenic stroke. Methods. From August 2019 to January 2020, a total of 213 patients with suspected PFO were included in our study. All patients underwent cTEE, cTCD, and cTTE examinations. cTTE3 was named for using a cutoff of 3 beats to detect PFO during cTTE, and cTTE5 represented a cutoff of 5 beats. A cutoff of cTCD grade III was named cTCD III. A cutoff of grade IV was named cTCD IV. cTTE3+cTCD IV was used for the combination of a cutoff of 3 beats during cTTE with grade IV of cTCD. cTTE5+cTCD III combined a cutoff of 5 beats during cTTE with cTCD grade III. Taking cTEE as the gold standard, we compared the sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate for PFO detection among the above methods. Results. A total of 161 of 213 (76%) patients had PFO confirmed by cTEE. With the spontaneous Valsalva maneuver, the sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate of cTTE3 in PFO diagnosis were 60%, 90%, 44%, and 10%, respectively, and those for cTTE5 were 76%, 78%, 31% and 22%, respectively. The sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate of cTCD III were 80%, 71%, 29%, and 29%, respectively, while those for cTCD IV were 55%, 90%, 49%, and 10%, respectively. When cTTE and cTCD were combined to diagnose PFO, the specificity and misdiagnosis rate were significantly improved, especially cTTE3+cTCD IV, with 100% specificity and a misdiagnosis rate of 0. Conclusion. cTTE or cTCD can be used for preliminary PFO related to cryptogenic stroke findings. The combination of the two methods can improve the specificity of PFO diagnosis, especially using the cutoff of cTTE3+cTCD IV.

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Comparison of transthoracic echocardiography using second harmonic imaging, transcranial Doppler and transesophageal echocardiography for the detection of patent foramen ovale in stroke patients

European Journal of Echocardiography ◽

10.1016/j.euje.2005.04.007 ◽

2006 ◽

Vol 7 (2) ◽

pp. 147-154 ◽

Cited By ~ 58

Author(s):

G SOUTEYRAND ◽

P MOTREFF ◽

J LUSSON ◽

R RODRIGUEZ ◽

E GEOFFROY ◽

...

Keyword(s):

Transesophageal Echocardiography ◽

Transcranial Doppler ◽

Transthoracic Echocardiography ◽

Patent Foramen Ovale ◽

Second Harmonic ◽

Harmonic Imaging ◽

Foramen Ovale ◽

Stroke Patients

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A comparison of transcranial Doppler, transthoracic echocardiography, and transesophageal echocardiography in the diagnosis of patent foramen ovale

Human Health and Medical Engineering ◽

10.2495/hhme130141 ◽

2014 ◽

Author(s):

Zi-Ming Yan ◽

Ying-Qi Xing ◽

Xiu-Juan Wu ◽

Kang-ding Liu

Keyword(s):

Transesophageal Echocardiography ◽

Transcranial Doppler ◽

Transthoracic Echocardiography ◽

Patent Foramen Ovale ◽

Foramen Ovale

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Differential Lesion Patterns on T2WI and FLAIR Sequences in Cryptogenic Stroke Patients With Patent Foramen Ovale

The Neurologist ◽

10.1097/nrl.0000000000000058 ◽

2015 ◽

Vol 20 (5) ◽

pp. 75-79 ◽

Cited By ~ 1

Author(s):

Yang-Yang Huang ◽

Bei Shao ◽

Xian-Da Ni ◽

Jian-Ce Li ◽

Xiao-Ting Niu ◽

...

Keyword(s):

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Stroke Patients

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Abstract 2922: Patent Foramen Ovale Is A Cause Of Ischemic Stroke In Patients With Antiphospholipid Syndrome

Stroke ◽

10.1161/str.43.suppl_1.a2922 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Yoshiaki Shimada

Keyword(s):

Ischemic Stroke ◽

Antiphospholipid Syndrome ◽

Patent Foramen Ovale ◽

Multiple Logistic Regression Analysis ◽

Cryptogenic Stroke ◽

Control Group ◽

Atrial Septal Aneurysm ◽

Foramen Ovale ◽

Stroke Patients ◽

Significant Difference

Background: The antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by a combination of arterial and/or venous thrombosis and recurrent fetal loss, and can be an independent risk factor for a first-ever ischemic stroke especially in young female patients. Patent foramen ovale (PFO) has been established as a cause of cryptogenic stroke. Atrial septal aneurysm (ASA) is associated with PFO. Until recently, the precise pathophysiology of APS as causing ischemic stroke has been essentially unknown. In the present study, we investigated the relationship between APS and potential embolic sources including PFO and ASA using transesophageal echocardiography (TEE). Methods: This study was a retrospective case series design. From July 2006 to June 2008, 120 patients with ischemic stroke who admitted to Juntendo University Hospital underwent TEE. In this study period, consecutive ischemic stoke patients diagnosed as APS based on the modified Sapporo criteria were enrolled and classified into APS group. Controls were selected among age- and gender-matched stroke patients without APS who also underwent TEE. We assessed clinical characteristics and presence of embolic sources including PFO and atrial septal aneurysm (ASA) between APS and Control groups. Results: Nine of ischemic stroke patients with APS and 41 controls were included. Primary APS was present in one patient (11.1%) of the APS group, and APS with SLE were found in eight patients (88.9%). There is no significant difference in age, risk factors for ischemic stroke, and MRI findings between two groups. The prevalence of PFO and ASA were significantly higher in APS group compared to Control group (89% vs 41%, P=0.027; 67% vs 20%, P=0.015, respectively). C reactive protein was relatively higher in APS group. Multiple logistic regression analysis showed that PFO (OR: 13.71; 95% CI: 1.01 to 185.62; P=0.049) and ASA (OR: 8.06; 95% CI: 1.17 to 55.59; P=0.034) were independently associated with the APS group. Conclusion: Atrial septal abnormalities including PFO and ASA are strongly associated with APS group, and could be potential embolic sources in ischemic stroke patients with APS.

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Abstract 204: Transcranial Doppler Versus Transthoracic Echocardiography for the Detection of Patent Foramen Ovale in Patients With Cryptogenic Cerebral Ischemia: A Systematic Review and Diagnostic Test Accuracy Meta-analysis

Stroke ◽

10.1161/str.47.suppl_1.204 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Georgios Tsivgoulis ◽

Aristeidis H Katsanos ◽

Theodora Psaltopoulou ◽

Theodoros Sergentanis ◽

Alexandra Frogoudaki ◽

...

Keyword(s):

Cerebral Ischemia ◽

Sensitivity And Specificity ◽

Transcranial Doppler ◽

Transthoracic Echocardiography ◽

Patent Foramen Ovale ◽

Diagnostic Yield ◽

Positive Likelihood Ratio ◽

Receiver Operating Curve ◽

Test Accuracy ◽

Foramen Ovale

Background & Purpose: 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 cerebral ischemia has not been compared with that of transcranial Doppler (TCD) using a comprehensive meta-analytical approach. Methods: We performed a systematic literature review according to PRISMA guidelines 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 summary 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%). The summary diagnostic odds ratio (DOR) for TCD (DOR=297.97, 95%CI: 131.18-676.83) and TTE (DOR=193.44, 95%CI: 30.38-1231.67) did not significantly differ (z-value=0.418, p=0.676). 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 yielded lower negative positive 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; Figure A) compared to TTE studies (AUC=0.86, 95%CI: 0.82-0.89; Figure B). Conclusions: TCD is more sensitive but less specific compared to TTE for the detection of PFO in patients with cryptogenic cerebral ischemia. The overall diagnostic yield of TCD appears to outweigh that of TTE.

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