Abstract WP214: Transcranial Color Coded Sonography versus Transcranial Doppler for the Detection of Right-to-left Shunt and Patent Foramen Ovale in Young Patients With Stroke

Introduction: Patent Foramen Ovale (PFO) is the most common right-to-left shunt (RLS) and is often found in young patients with stroke related to paradoxical embolism. Contrast-Enhanced Transesophageal Echocardiography (TEE) is considered a gold standard to visualize PFO. Transcranial Doppler (TCD) with bubble test is often used to detect RLS with good correlation to TEE for the diagnostic of PFO. More recently, Transcranial Color Coded Sonography (TCCS) which included B-mode and color coded imaging has overcome TCD in many clinical applications but the accuracy of TCCS for detection of RLS and PFO has not been systematically evaluated. Hypothesis: To determine if the TCCS is an accurate tool to identify both PFO and RLS. Methods: We investigate 106 patients with ischemic stroke under 55 years-old admitted from 2012 to 2014 in a tertiary academic hospital. Patients were evaluated with TEE, TCD and TCCS, and all exams included a saline bubble test. The examiners were blinded for the other tests results. Kappa agreement was calculated inter-examiners for TCCS and TCD. Accuracy of TCCS was calculated in comparison to TEE. Results: We detected a RLS in 54 (50.9%) patients (age mean 43.9 ± 8.2) with kappa agreement 0.92 (95%CI 0.78-1.0) when performed TCCS and TCD. TEE and TCSS were positive in 23/98 (23.4%) and TEE did not reveal contrast in 20/98 (20.4%). In 30 (28.3%) patients only TEE revealed a PFO. TCSS had a sensitivity of 88.4% (95%CI 0.68-0.97), specificity of 72.2% (95%CI 0.60-0.81) and positive likelihood ratio of 3.18 (2.14-4.73) of the diagnosis of PFO. Conclusion: TCCS and TCD had an excellent agreement. TCCS has a good accuracy for the detection of PFO and RLS in young patients with stroke.

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Right-to-left shunt and the hypercoagulable state: does paradoxical embolism play a role in patients with antiphospholipid syndrome and stroke?

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2012000800004 ◽

2012 ◽

Vol 70 (8) ◽

pp. 578-582 ◽

Cited By ~ 2

Author(s):

Laura Nicoleti Zamproni ◽

Viviane Flumignan Zétola ◽

Marcos Christiano Lange

Keyword(s):

Antiphospholipid Syndrome ◽

Transcranial Doppler ◽

High Intensity ◽

Patent Foramen Ovale ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Contrast Enhanced ◽

Significant Difference ◽

Stroke Group ◽

History Of

OBJECTIVE: Patent foramen ovale is associated with paradoxical embolism (PE) and stroke. Hypercoagulable states, such as antiphospholipid syndrome (APS), can exacerbate PE by increasing clot formation. The aim of this study was to verify whether patients with APS and stroke present a right-to-left shunt (RLS) with greater frequency than patients with APS but without stroke. METHODS: Fifty-three patients with APS were tested for RLS using contrast-enhanced transcranial Doppler (cTCD): 23 patients had a history of stroke (Stroke Group) and 30 had no history of stroke (No-stroke Group). RESULTS: cTCD was positive in 15 patients (65%) from the Stroke Group and in 16 patients (53%) in the No-stroke Group (p=0.56). The proportion of patients with a small RLS (<10 high-intensity transient sign or HITS) and a large RLS (>10 HITS) was similar between the groups without significant difference. CONCLUSIONS: Our data do not support the theory that paradoxical embolism may play an important role in stroke in APS patients.

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Transcranial Doppler for patent foramen ovale screening: is there a good correlation with transesophageal echocardiography?

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2008000600001 ◽

2008 ◽

Vol 66 (4) ◽

pp. 785-789 ◽

Cited By ~ 10

Author(s):

Marcos Christiano Lange ◽

Viviane Flumignan Zétola ◽

Admar Moraes de Souza ◽

Élcio Juliato Piovesan ◽

Juliano André Muzzio ◽

...

Keyword(s):

Positive Predictive Value ◽

Transcranial Doppler ◽

Predictive Value ◽

Screening Test ◽

Patent Foramen Ovale ◽

Foramen Ovale ◽

Negative Results ◽

Contrast Enhanced ◽

Group 2 ◽

Group 1

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.

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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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Prevalence of Patent Foramen Ovale in Migraine Patients with and Without Aura Compared with Stroke Patients. A Transcranial Doppler Study

Cephalalgia ◽

10.1111/j.1468-2982.2006.01156.x ◽

2006 ◽

Vol 26 (8) ◽

pp. 934-939 ◽

Cited By ~ 54

Author(s):

FJ Carod-Artal ◽

L da Silveira Ribeiro ◽

H Braga ◽

W Kummer ◽

HM Mesquita ◽

...

Keyword(s):

Transcranial Doppler ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Transcranial Doppler Sonography ◽

Young Patients ◽

Data Bank ◽

Foramen Ovale ◽

Stroke Patients ◽

Doppler Study ◽

The Difference

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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Detection of Patent foramen Ovale with Contrast Enhanced Transcranial Doppler at Divers

Polish Hyperbaric Research ◽

10.2478/phr-2019-0008 ◽

2019 ◽

Vol 67 (2) ◽

pp. 93-102

Author(s):

Krzysztof Dziewiatowski ◽

Piotr Siermontowski

Keyword(s):

Left Atrium ◽

Sensitivity And Specificity ◽

Transcranial Doppler ◽

Patent Foramen Ovale ◽

Decompression Sickness ◽

Adult Population ◽

Venous Blood ◽

Arterial System ◽

Foramen Ovale ◽

Contrast Enhanced

Abstract Patent foramen ovale (PFO) is a condition present in 25% of the adult population. It is a remnant of fetal foramen ovale which allows blood to pass from the right to the left atrium, bypassing the fetal lungs. In majority adults it does not have any clinical significance, but in some people it may allow shunting of venous blood into the left atrium (right – left – shunt or RLS), circumventing the lung filter, especially during sneezing, cough, lifting heavy equipment. Is such case, PFO may be a route for venous emboli or gas bubbles from veins to the arterial system. It is known as a paradoxical embolism and may be cause of ischaemic stroke or neurologic decompression sickness (DCI), inner-ear DCI and cutis marmorata. Transesophageal echocardiography is considered as a reference standard in detection of intracardial shunts. Its sensitivity and specificity ranges between 94%-100%. However, TEE is an invasive examination with potentially serious side effects. An alternative examination in RLS detection is contrast enhanced Transcranial Doppler (the bubble study or c-TCD). In comparison to TEE, Transcranial Doppler is not invasive, relatively not expensive and save technique. With its high sensitivity and specificity in detection of PFO, 97% and 93% respectively, it may improve detection of RLS and allow to conduct screening examination for PFO in divers.

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Paradoxical emboli: Clinical importance of transcranial doppler for detection of patent foramen ovale

Medicinski pregled ◽

10.2298/mpns1008445z ◽

2010 ◽

Vol 63 (7-8) ◽

pp. 445-449

Author(s):

Zeljko Zivanovic ◽

Svetlana Ruzicka-Kaloci ◽

Aleksandar Jesic ◽

Biljana Radovanovic ◽

Aleksandra Lucic-Prokin ◽

...

Keyword(s):

Transesophageal Echocardiography ◽

Transcranial Doppler ◽

Patent Foramen Ovale ◽

Doppler Sonography ◽

Contrast Echocardiography ◽

Cryptogenic Stroke ◽

Transcranial Doppler Sonography ◽

Foramen Ovale ◽

Predictive Values ◽

Bubble Test

A patent foramen ovale has been reported to be more frequently detected in cryptogenic stroke, with paradoxical embolism as the major pathogenetic mechanism. The standard procedure for the detection of a patent foramen ovale is transesophageal echo?cardiography. Transcranial Doppler sonography with bubble test is almost as reliable as transesophageal echocardiography. Seventeen patients with acute ischemic stroke and transient ischemic attacks hospitalized at the Department of Neurology in Novi Sad underwent examinations to detect a patent foramen ovale, which was found in 55.6% of patients with cryptogenic stroke. The average age of these patients was 30.6 years. Transcranial Doppler sonography showed 100% sensitivity and 100% specificity for the predicti?on of right-to-left shunts proven by transesophageal contrast echocardiography. Both positive and negative predictive values in our group of patients were 1. Transcranial Doppler with bubble test is a reliable method for the detection of a patent foramen ovale, with a high level of sensitivity and specificity which is comparable with transesophageal echocardiography. Moreover, it is cheaper and more comfortable than transesophageal echocardiography, and should be used routinely in neurological practice.

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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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Incidental diagnosis of four pulmonary arteriovenous fistulas during patent foramen ovale closure: a case report

Cardiology in the Young ◽

10.1017/s1047951120002152 ◽

2020 ◽

Vol 30 (9) ◽

pp. 1363-1365

Author(s):

Alessandro Andreis ◽

Gabriella Agnoletti ◽

Paolo Scacciatella

Keyword(s):

Patent Foramen Ovale ◽

Clinical Case ◽

Septal Defect ◽

Cryptogenic Stroke ◽

Young Patients ◽

Transoesophageal Echocardiography ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Arteriovenous Fistulas ◽

Pulmonary Arteriovenous Fistulas

AbstractCryptogenic cerebral ischemia in young patients is commonly ascribed to paradoxical embolism. We report the clinical case of a young patient with cryptogenic stroke and a patent foramen ovale, undergoing percutaneous closure of atrial septal defect. Contrast transoesophageal echocardiography at the end of the procedure demonstrated massive late residual right-to-left shunt, due to the coexistence of pulmonary arteriovenous fistulas that were subsequently closed. Routinary adoption of contrast transoesophageal echocardiography at the end of patent foramen ovale closure interventions may be useful to detect early and late residual shunts. Late residual shunts may be due to pulmonary fistulas, a well-known risk factor for recurrent thromboembolic events.

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Safety and efficacy of endovascular patent foramen ovale closure: the first results of a Russian multicenter study

Neurology neuropsychiatry Psychosomatics ◽

10.14412/2074-2711-2020-6-26-32 ◽

2020 ◽

Vol 12 (6) ◽

pp. 26-32

Author(s):

D. V. Ognerubov ◽

A. S. Tereshchenko ◽

A. N. Samko ◽

G. К. Arutyunyan ◽

O. A. Sivakova ◽

...

Keyword(s):

Ischemic Stroke ◽

Secondary Prevention ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Young Patients ◽

Paradoxical Embolism ◽

Atrial Septal Aneurysm ◽

Foramen Ovale ◽

History Of ◽

Pfo Closure

Patent foramen ovale (PFO) is detectable in more than 25% of the adult population and is generally clinically insignificant. However, it can be a cause of paradoxical embolism in some cases. Randomized trials indicate that endovascular PFO closure in patients with a history of cryptogenic stroke is an effective method for the secondary prevention of catastrophic brain damage.Objective: to study the safety and efficiency of endovascular PFO closure in young patients with a history of cryptogenic stroke.Patients and methods. Sixty-two patients, including (22 males and 40 females) women, underwent percutaneous PFO closure in May 2018 to March 2020. The patients' mean age was 37.4±7.6 years. The inclusion criteria were a prior cryptogenic ischemic stroke lasting less than 12 months and PFO with a high risk for paradoxical embolism (PFO concurrent with atrial septal aneurysm or hypermobility; PFO, ≥2 mm size; the presence of the Chiari network and/or the Eustachian valve).Results and discussion. The technical success of the operation was achieved in all cases. In 50 (80.6%) patients, the right chamber of the heart was completely isolated from the left one in the first 3 months. During the first year, the atria were also completely isolated in 10 (16.1%) patients. A left-to-right shunt persisted in 2 (3.2%) patents 12 months later. Two patients were found to have main procedural complications: one had perioperative atrial fibrillation and the other had pseudoaneurysm formation at the puncture site.Conclusion. Endovascular PFO closure is a safe and effective operation for the secondary prevention of recurrent ischemic stroke. In our study, blood shunting through the PFO was stopped in 96.6% of patients at less than 6 months after surgery, which suggests that there is a rapid and effective reduction in the risk of paradoxical embolism.

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A score of non-contrast transthoracic echocardiography to detect patent foramen ovale

10.21203/rs.2.23005/v1 ◽

2020 ◽

Author(s):

Hui Zhang ◽

Haiyan Tang ◽

Fei Wu ◽

Chun Yu ◽

Qiang Dong ◽

...

Keyword(s):

Mitral Regurgitation ◽

Aortic Root ◽

Transcranial Doppler ◽

Transthoracic Echocardiography ◽

Patent Foramen Ovale ◽

Root Diameter ◽

Foramen Ovale ◽

Bubble Test ◽

Group A ◽

Lower Incidence Rate

Abstract Backgroud: The aim of this study was to develop a screening score of non-contrast transthoracic echocardiography (TTE) for patent foramen ovale (PFO) in patients with embolic stroke of undetermined source (ESUS).Methods: We performed a retrospective analysis of 218 consecutive patients with a recent ESUS from 2015 to 2018, who received TTE and transcranial Doppler (TCD) as routine examinations. PFO was diagnosed by the bubble test of TCD. Significant differences of the TTE findings between PFO group and non-PFO group were selected into a score.Results: PFO was diagnosed in 35.8% (78/218) of the patients. Compared with non-PFO group, a larger median aortic root diameter (ARd) (34mm vs. 32mm, p=0.005), a lower median peak E wave velocity (Em) (61.5cm/s vs. 68cm/s, p=0.005) and a lower incidence rate of mitral regurgitation (33.8% vs. 50.7%, p=0.016) were seen in PFO group. A three-point score of TTE criteria (including aortic root diameter>33mm, Em<72cm/s and without mitral regurgitation, AEM) was tested to be independently predict PFO (odd risk 1.95, 95%CI 1.37~2.78, p<0.001). AEM score ≥2 detected PFO with a sensitivity of 0.71 (95% CI 0.67~0.85) and a specificity of 0.53 (95% CI 0.44 - 0.55).Conclusion: The AEM score measured with non-contrast TTE can select ESUS patients for bubble test of TCD to detect PFO.

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