Detection of Paradoxical Cerebral Embolism Using Transcranial Doppler in a Patient with Infarct of Undetermined Cause

Massaro, Ayrton Roberto; Hoffmann, Michael; Sacco, Ralph L.; Tullio, Marco Di; Homma, Shunichi; Mohr, J. P.

doi:10.1159/000108683

Cited by 5 publications

(6 citation statements)

References 10 publications

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“…On the contrary, TCD is easily performed and causes no discomfort to the patient. Moreover, it theoreti cally represents the ideal method to cerebral conse quences of PFO as it is the only technique able to detect the passage of emboli across the brain arteries in real time [1][2][3], However, TCD used on its own in the cerebral ves sels after peripheral injection of agitated saline may lead to the erroneous diagnosis of PFO if timing is not taken into account, as a significant proportion of the contrast medium may escape the pulmonary filter because of eith er intrapulmonary shunts or repeated transpulmonary passages [2,7]. This, of course, may dramatically reduce the specificity of the method.…”

Section: Discussionmentioning

confidence: 99%

“…Transcranial Doppler sonography (TCD) can detect the passage through the middle cerebral artery of micro bubbles present in intravenously injected saline when an intracardiac right-to-left shunt occurs [1][2][3]. Since TCD is a simple, cheap and harmless procedure, it may represent the ideal tool for large-scale studies on the real importance of patent foramen ovale (PFO) as a possible anatomical factor predisposing to stroke [4][5][6], provided its sensitivi- ty and specificity are accurately assessed.…”

Section: Introductionmentioning

confidence: 99%

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Validation of Transcranial Doppler Sonography in the Assessment of Patent Foramen Ovale

et al. 1995

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Transcranial Doppler sonography (TCD) can detect the passage through the middle cerebral artery of microbubbles present in intravenous injected saline when an intracardiac right-to-left shunt occurs. Given the increasingly recognized importance of patent foramen ovale (PFO) as a possible anatomical factor predisposing to stroke, we tried to assess the efficiency of TCD in the evaluation of PFO in comparison to the gold standard represented by transesophageal echocardiography (TEE). Seventy-two consecutive patients scheduled for TEE also underwent TCD, simultaneously in 18 cases. A 20-ml agitated saline bolus was injected into an antecubital vein through an indwelling catheter while the patient was performing a Valsalva manoeuvre. The procedure was repeated a maximum of 10 times or until the contrast medium was tracked from the right to left atrium (TEE+) and/or the high-intensity spike typical for embolism was recorded on TCD (TCD+). Among non-simultaneous cases, the first 14 were studied with a non-standardized protocol: the resulting sensitivity and specificity of TCD as compared to TEE were both 43% (TEE+/TCD+ = 3; TEE–/TCD– = 3; TCD+/TEE– = 4; TCD–/TEE+ = 4). In all the 18 simultaneous examinations, however, there was 100% agreement between TEE and TCD (TEE+/TCD+ = 12; TEE–/TCD– = 6). Moreover, when the protocol was standardized in 40 further patients studied non-simultaneously, sensitivity and specificity were 90 and 100%, respectively (TCD+/TEE+ = 19; TCD–/ TEE– = 19; TCD–/TEE+ = 2; TCD+/TEE– = 0) Standardization was obtained by timing of Valsalva manoeuvre to injection, delay of embolic signals, caliber of venous catheters, content of air bubbles in the saline, velocity of injection. In conclusion, when properly standardized techniques are applied, TCD can be used as a screening test for the detection of PFO.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Validation of Transcranial Doppler Sonography in the Assessment of Patent Foramen Ovale

et al. 1995

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“…In addition, TEE allows for reliable exclusion of other potential cardiac sources of embolism. Indirect proof of PFO can be derived with transcranial contrast Doppler ultrasound demonstrating delivery of microbubbles to the cranial circulation [9]. Multiplane TEE with saline echocontrast and Valsalva maneuver remains the most sensitive and specific method for the detection of PFO [10], allowing for sizing of the PFO and demonstration of the degree of right-to-left shunting.…”

Section: Opinion Statementmentioning

confidence: 99%

Patent foramen ovale and stroke

Rodríguez

Homma

2003

Curr Treat Options Cardio Med

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Observational data from prospective and retrospective trials indicate that a patent foramen ovale (PFO) is associated with the risk of ischemic stroke. The mechanism involved is presumed to be paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation causing an ischemic stroke. Primary stroke prevention data for patients with a PFO are nonexistent. Given the substantial prevalence of PFO in the total population (~ 25% to 30%), a primary prevention study may not be feasible. However, whether targeted primary prevention for patients with PFOs of certain morphologic characteristics (eg, larger size, greater degree of shunt) would be possible remains undefined. Given the large number of asymptomatic subjects, no therapy is currently recommended. The best treatment modality to prevent recurrent stroke in patients with PFO has not been defined. There are four major treatment choices: surgical closure, percutaneous device closure, medical therapy with anticoagulants, and medical therapy with antiplatelet agents. Regarding medical therapy, the Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent adverse events. Although closure of the PFO, either surgical or percutaneous, may further reduce the event rates, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.

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“…Indirect proof of PFO can be derived with transcranial contrast Doppler ultrasound demonstrating delivery of microbubbles to the cranial circulation [9]. Multiplane TEE with saline echocontrast study and Valsalva maneuver remains the most sensitive and specific method for the detection of PFO [10], allowing for sizing of the PFO and demonstration of the degree of right-to-left shunting.…”

Section: Introductionmentioning

confidence: 99%

Management of patients with stroke and a patent foramen ovale

Rodríguez

Homma

2004

Curr Cardiol Rep

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Observational studies have established a strong association between the presence of patent foramen ovale (PFO) and increased risk of ischemic stroke. The mechanism involved is presumed to be a paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation. The best treatment modality to prevent recurrent stroke in patients with PFO remains undefined. There are four major choices: 1) medical therapy with anticoagulants, 2) medical therapy with antiplatelet agents, 3) surgical closure, and 4) percutaneous device closure. The Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent neurologic events in stroke patients with a PFO. Medical therapy should remain as the initial choice of secondary prophylactic therapy. PFO closure, either surgical or percutaneous, may further reduce event rates; however, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.

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Detection of Paradoxical Cerebral Embolism Using Transcranial Doppler in a Patient with Infarct of Undetermined Cause

Cited by 5 publications

References 10 publications

Validation of Transcranial Doppler Sonography in the Assessment of Patent Foramen Ovale

Validation of Transcranial Doppler Sonography in the Assessment of Patent Foramen Ovale

Patent foramen ovale and stroke

Management of patients with stroke and a patent foramen ovale

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