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

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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Current status of transcatheter closure of patent foramen ovale

Gaceta Médica de Caracas - Supplement 1 ◽

10.47307/gmc.2020.128.3.8 ◽

2020 ◽

Vol 128 (3) ◽

pp. 296-306

Author(s):

Igor F. Palacios

Keyword(s):

Transcranial Doppler ◽

Patent Foramen Ovale ◽

Decompression Sickness ◽

Adult Population ◽

Cryptogenic Stroke ◽

Current Status ◽

Diagnostic Tools ◽

Foramen Ovale ◽

Exercise Induced ◽

Ischemic Attack

A patent foramen ovale (PFO) is a highly prevalent structure among the adult population. It allows the shunt of blood through the inter-atrial septum and has been associated with cryptogenic stroke, transient ischemic attack, significant right to left shunting resulting in resting and exercise-induced hypoxemia, platypnea orthodeoxia syndrome, and decompression sickness after scuba diving and migraines. Currently, transthoracic and transesophageal echocardiography and transcranial Doppler are the most important diagnostic tools, for the diagnosis of PFO. The sensitivity and specificity of the study depend on the modalities available: transthoracic (TTE), transesophageal (TEE), and transcranial Doppler (TCD), as well as the intravenous use of agitated saline and the site of injection.

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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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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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Patent Foramen Ovale Closure: State of the Art

Interventional Cardiology Review ◽

10.15420/icr.2019.27 ◽

2020 ◽

Vol 15 ◽

Author(s):

Joel P Giblett ◽

Lynne K Williams ◽

Stephen Kyranis ◽

Leonard M Shapiro ◽

Patrick A Calvert

Keyword(s):

Patent Foramen Ovale ◽

Decompression Sickness ◽

Recurrent Stroke ◽

Adult Population ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Arterial Circulation ◽

Arterial Embolisation ◽

Randomised Control Trials ◽

Paradoxical Embolus

Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people, it is a benign finding; however, in some people, the PFO can open widely to enable paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of the PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised control trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this article considers the evidence for PFO closure in cryptogenic stroke. The article also addresses other potential indications for closure, including systemic arterial embolisation, decompression sickness, platypnoea–orthodeoxia syndrome and migraine with aura. The article lays out the pre-procedural investigations and preparation for the procedure. Finally, the article gives an overview of the procedure itself, including discussion of closure devices.

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Is the patent foramen ovale closure the best option?

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2012001200006 ◽

2012 ◽

Vol 70 (12) ◽

pp. 934-938

Author(s):

Viviane Flumignan Zetola ◽

Melissa Castello Branco e Silva ◽

Marcos Christiano Lange ◽

Juliano Andre Muzzio ◽

Edison Matos Novak ◽

...

Keyword(s):

Transcranial Doppler ◽

Patent Foramen Ovale ◽

Valsalva Maneuver ◽

Foramen Ovale ◽

Contrast Enhanced ◽

Number Of Patients ◽

Study Results ◽

Before And After ◽

One Year ◽

Pfo Closure

Patent foramen ovale (PFO) closure is indicated in some cases to protect patients against embolic events. The aim of this study was to certify that the method of PFO closure to prevent microemboli (MES) is reliable, using contrast enhanced transcranial Doppler (cTCD) as a diagnostic and follow-up tool. METHODS: cTCD was performed before and after PFO closure in 20 patients. Results obtained a minimum of 12 months after the procedure were analyzed in this study. RESULTS: After the procedure, 14 patients (82%) showed no microemboli in cTCD at rest, but after provocative Valsalva maneuver (VM) microembolic phenomenon were still detected in 14 (70%): 7 (35%) <10 MES, 3 (15%) 10-20 MES and 4 (20%) had more than 20 MES ("curtain"). Only six of the total patients presented no MES in both resting and VM. CONCLUSION: These results showed a large percentage of patients with MES detection in a bubble study with transcranial Doppler more than one year after the procedure of PFO closure, showing right-to-left residual shunting. Despite the small number of patients, this study provides important data about this therapeutic decision.

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Cerebral Microembolism Diagnosed by Transcranial Doppler during Total Knee Arthroplasty

Anesthesiology ◽

10.1097/00000542-199909000-00018 ◽

1999 ◽

Vol 91 (3) ◽

pp. 672-672 ◽

Cited By ~ 79

Author(s):

Cheri A. Sulek ◽

Laurie K. Davies ◽

Kayser F. Enneking ◽

Peter A. Gearen ◽

Emilio B. Lobato

Keyword(s):

Total Knee Arthroplasty ◽

Left Atrium ◽

Knee Arthroplasty ◽

Transcranial Doppler ◽

Patent Foramen Ovale ◽

Foramen Ovale ◽

Tourniquet Release ◽

Total Knee ◽

Cerebral Microembolism ◽

Tourniquet Deflation

Background Tourniquet deflation following total knee arthroplasty (TKA) frequently results in release of emboli into the pulmonary circulation. Small emboli may gain access to the systemic circulation via a transpulmonary route or through a patent foramen ovale. This study examined the incidence of cerebral microembolism after tourniquet release by transcranial Doppler (TCD) ultrasonography and its correlation with echogenic material detected in the left atrium. Methods Twenty-two adult patients (9 men, 13 women) undergoing TKA were studied with simultaneous TCD ultrasonography and transesophageal echocardiography. Data were recorded after anesthesia induction and tourniquet inflation and during tourniquet deflation. Emboli counts were performed manually off-line. Echogenic material in the left atrium was qualitatively assessed and correlated with TCD data. Patients were examined postoperatively for focal neurologic deficits. Results Fifteen patients had unilateral TKA (six left, nine right) and seven had bilateral TKA. Cerebral emboli were detected in 9 of 15 patients (60%) with unilateral TKA and in 4 of 7 patients (57%) with bilateral TKA. Echogenic material was identified in the left atrium in eight patients (two through a patent foramen ovale and six from the pulmonary veins). Emboli counts were significantly higher in patients with bilateral TKA compared with those with unilateral TKA (P<0.05). Duration of tourniquet time in patients with emboli was longer only during bilateral TKA (P<0.05). All patients with echogenic material in the left atrium detected by transesophageal echocardiography had emboli as assessed by TCD ultrasonography. No focal neurologic deficits were identified. Conclusions Cerebral microembolism occurs frequently during tourniquet release, even in the absence of a patient foramen ovale. This passage most likely occurs through the pulmonary capillaries or the opening of recruitable pulmonary vessels.

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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

Stroke ◽

10.1161/str.47.suppl_1.wp214 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Milena C Libardi ◽

Millene R Camilo ◽

Soraia R Fabio ◽

Rui Kleber V Martins Filho ◽

Letícia J Rocha ◽

...

Keyword(s):

Transcranial Doppler ◽

Patent Foramen Ovale ◽

Young Patients ◽

Positive Likelihood Ratio ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Contrast Enhanced ◽

Hospital Patients ◽

Bubble Test ◽

Kappa Agreement

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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