Transcranial Doppler: Does Addition of Blood to Agitated Saline Affect Sensitivity for Detecting Cardiac Right‐to‐Left Shunt?

Mojadidi, Mohammad K.; Zhang, Lili; Chugh, Yashasvi; Eshtehardi, Parham; Hovnanians, Ninel; Gevorgyan, Rubine; Mojaddedi, B S Sanaullah; Nezami, Nariman; Zaman, Muhammad Omer; Rafique, Asim; Villablanca, Pedro A.; Tobis, F.A.C.C. Jonathan M.

doi:10.1111/echo.13231

Cited by 14 publications

(7 citation statements)

References 48 publications

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“…Agitated saline with addition of 0·5 mL of the patient's blood and 0·5 mL of air was used as a contrast agent in all cases according to accepted guidelines ( appendix ). 19 , 20 A large RLS was defined as a shunt with 20 or more microbubbles recorded. Since Nov 15, 2015, if a temporal bone window was not suitable for monitoring, the basilar artery was monitored through a transoccipital approach.…”

Section: Methodsmentioning

confidence: 99%

“… 2 , 7 , 12 For studies using bubble-TCD, a definition based on the current consensus was used. 19 , 20 Extracted information included PFO screening modality (transthoracic echocardiography, transoesophageal echocardiography, or bubble-TCD), type of event (stroke or transient ischaemic attack), setting, case enrolment (consecutive vs non-consecutive), cryptogenic event out of all events ratio, stroke subtype classification (TOAST vs other), mean age of the population, age stratification, and excluded cases with reasons for exclusion, when provided.…”

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages: a population-based study, systematic review, and meta-analysis

Mazzucco

Binney

et al. 2018

The Lancet Neurology

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SummaryBackgroundPercutaneous closure of patent foramen ovale (PFO) has been shown to be superior to medical treatment alone for prevention of recurrent stroke after cryptogenic transient ischaemic attack or non-disabling stroke in patients aged 60 years or younger. The justification for trials in older patients with transient ischaemic attack or stroke depends on whether PFO is shown to be associated with cryptogenic events at older ages, for which existing evidence is conflicting, and on the population burden of PFO-associated events. Therefore, we did a population-based screening study using contrast-enhanced transcranial Doppler (bubble-TCD) to detect probable PFO as indicated by a right-to-left shunt (RLS); we also did a systematic review and meta-analysis to compare our results with previous studies.MethodsIn this population-based study, nested in the Oxford Vascular Study (OXVASC), we established the prevalence of any RLS, and of large RLS (>20 microbubbles), in consecutive patients attending a rapid-access transient ischaemic attack and stroke clinic, or at 1-month follow-up after stroke unit admission, with transient ischaemic attack or non-disabling ischaemic stroke, comparing cryptogenic events with those of known cause (according to Trial of Org 10172 in Acute Stroke Treatment [TOAST] criteria). We stratified participants by age, and extrapolated data to the UK population. We also did a systematic review of published studies of PFO prevalence (using transthoracic or transoesophageal echocardiography or bubble-TCD) according to stroke subtype, which included older patients and reported age-specific results, and determined by meta-analysis (including the OXVASC data) the pooled odds ratio (95% CI) of finding PFO of any size in cryptogenic events compared with events of known cause, stratified by screening modality (transthoracic or transoesophageal echocardiography or bubble-TCD). The study protocol is registered with PROSPERO, number CRD42018087074.FindingsAmong 572 consecutive patients with transient ischaemic attack or non-disabling stroke between Sept 1, 2014, and Oct 9, 2017 (439 [77%] patients aged >60 years, mean age 70·0 years [SD 13·7]), bubble-TCD was feasible in 523 patients (91%) of whom 397 were aged older than 60 years. Compared with those with transient ischaemic attack or stroke of known cause, patients with cryptogenic events had a higher prevalence of RLS overall (odds ratio [OR] 1·93, 95% CI 1·32–2·82; p=0·001), and in those aged older than 60 years (2·06, 1·32–3·23; p=0·001). When we pooled the OXVASC data with that from two previous smaller studies of bubble-TCD in patients aged 50 years or older, we found an association between RLS and cryptogenic events (OR 2·35, 95% CI 1·42–3·90; p=0·0009; pheterogeneity=0·15), which was consistent with the equivalent estimate from transoesophageal echocardiography studies (2·20, 1·15–4·22; p=0·02; pheterogeneity=0·02). No data on large RLS in patients with TOAST-defined cryptogenic events compared with other events were available from previous s...

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages: a population-based study, systematic review, and meta-analysis

Mazzucco

Binney

et al. 2018

The Lancet Neurology

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“…Studies have reported variations in the RLS diagnosis rate when using different contrast agents ( 19 , 20 ). Compared to commercial contrasts and AS without blood, the addition of blood increases the sensitivity of c-TCD to as high as 100% ( 10 ). Further, the blood amount in the AS is controversial given clinical safety and practices.…”

Section: Discussionmentioning

confidence: 99%

“…Differently, Hao and colleagues demonstrated the superiority of adding one drop of blood to AS in detecting RLS ( 9 ). No matter how much of blood was added, the mechanism for improving c-TCD performance might come from the enhancement by red blood cells or more bubbles ( 10 , 11 ). In this study, we compared the characterization of microbubbles induced by AS without blood, AS with 5% blood (5% BAS), and AS with 10% blood (10% BAS), which were common agents applied in clinical practice, in vitro and compared the positive rate and RLS classification by c-TCD in patients using 3 contrast agents to investigate the correlation between the characterization of AS with blood and the clinical performance of c-TCD.…”

Section: Introductionmentioning

confidence: 99%

Agitated saline with 10% blood increases number and stability of microbubbles in detection right-to-left shunt by contrast-enhanced transcranial Doppler: an in vitro and in vivo observational study

Li¹,

Shen²,

Deng³

et al. 2023

J Thorac Dis

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Background Agitated saline (AS) with blood has been shown to have good tolerance and increased efficacy when used in contrast-enhanced transcranial Doppler (c-TCD) to detect right-to-left shunt (RLS). However, little is known about the effects of blood volume on c-TCD results. Our study investigated the characterization of AS with different blood volumes in vitro and compared the c-TCD results in vivo . Methods In vitro , AS without blood, AS with 5% blood (5% BAS), and AS with 10% blood (10% BAS) were prepared based on previous studies and observed under microscopy. The numbers and sizes of the microbubbles from different contrast agents were compared immediately, 5 min, and 10 min post-agitation. In vivo , 74 patients were recruited. c-TCD was repeated 3 times using AS with different blood volumes in each patient. Signal detection times, positive rates, and classifications of RLS were compared among the 3 groups. Results In vitro , the AS without blood produced 5.4±2.4/field microbubbles after agitation, the 5% BAS produced 30.4±4.2/field, and the 10% BAS produced 43.9±12.7/field. More microbubbles remained in the 10% BAS than the 5% BAS within 10 min (18.5±6.1 vs. 7.1±2.0/field, P<0.001). The size of the microbubbles from the 5% BAS increased from 9.2±8.2 to 22.1±10.6 µm within 10 min post-agitation (P=0.014), while the 10% BAS changed insignificantly. In vivo , the signal detection times of the 5% BAS (1.1±0.7 s) and 10% BAS (1.0±0.8 s) were significantly shorter than the AS without blood (4.0±1.5 s, P<0.0001). The RLS positive rates were 63.5%, 67.6% and 71.6% in AS without blood, 5% BAS and 10% BAS respectively; however, the differences were not statistically significant. The AS without blood reached 12.2% level III RLS, while the 5% BAS reached 25.7%, and the 10% BAS reached 35.1% (P=0.005). Conclusions The 10% BAS would be suggested in c-TCD as it addressed larger RLS by increasing the number and stability of microbubbles, and it improves the diagnosis of patent foramen ovale (PFO).

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“…But the TTE and TEE assessment of the severity of the shunt or the size of the PFO is often misleading when compared to balloon sizing measurements made in the catheterization laboratory. [3][4][5][6][7][8] The echo report may say that the PFO size is small, with the implication that the PFO would be too small to permit a thrombus to pass through and cause the patient's stroke. But during cardiac catheterization, the PFO may be an average size (7 mm) or larger.…”

Section: Echocardiographic Bubble Studies and The Best Way To Diagnos...mentioning

confidence: 99%

Transcranial Doppler: Does Addition of Blood to Agitated Saline Affect Sensitivity for Detecting Cardiac Right‐to‐Left Shunt?

Abstract: The addition of blood to agitated saline improves the sensitivity of TCD for the detection of RLS to 100% when compared to other conventional contrast agents; these findings support the addition of blood to agitated saline during TCD bubble studies.

Cited by 14 publications

References 48 publications

Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages: a population-based study, systematic review, and meta-analysis

Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages: a population-based study, systematic review, and meta-analysis

Agitated saline with 10% blood increases number and stability of microbubbles in detection right-to-left shunt by contrast-enhanced transcranial Doppler: an in vitro and in vivo observational study

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