Transcranial Doppler to Detect Right to Left Communication: Evaluation Versus Transesophageal Echocardiography in Real Life

Maillet, Alexandre; Pavero, A; Salaun, Pierre–Yves; Pibourdin, Alexis; Skopinski, S.; Thambo, Jean-Benoît; Sibon, Igor; Constans, J.; Boulon, Carine

doi:10.1177/0003319717712356

Cited by 13 publications

(14 citation statements)

References 25 publications

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“…However, accuracy may vary by center, protocol, and diagnostic criteria, with sensitivity ranging from 70% to 100% and specificity >95%, as estimated by the subcommittee of the American Academy of Neurology (Wessler et al, 2015). Furthermore, one can raise the question as to whether TEE is the real gold standard for RLS detection as in some cases, it failed to detect an existing shunt (Rodrigues et al, 2013;Caputi et al, 2009;Maillet et al, 2018), and a few studies have shown even higher sensitivity of cTCD compared to TEE (Jauss & Zanette, 2000) and the simplified version of the Spencer scale appeared to accurately predict shunt degree, with possibly higher cutoff limit specificity at 30 microembolic signals for large shunts, as previously suggested by Lao and colleagues (Lao et al, 2008).…”

Section: Discussionmentioning

confidence: 99%

“…(Wessler et al, 2015;Maillet et al, 2018;Tobe, Bogiatzi, Munoz, Tamayo, & Spence, 2016), which is probably at least partially due to difficulty in correctly performing the Valsalva maneuver during TEE. In our opinion, TCD with "bubble test" performed according to rigorously standardized procedure should be ensured to all young and middle-aged cryptogenic acute ischemic stroke patients as the screening test for RLS detection given the fact that it is extremely accurate, noninvasive, low expensive, rapidly available and safe.…”

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confidence: 99%

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Transcranial Doppler to detect right‐to‐left shunt in cryptogenic acute ischemic stroke

et al. 2018

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ObjectivesWe aimed to confirm the sensitivity and specificity of contrast transcranial Doppler (cTCD) in the detection of right‐to‐left shunt (RLS) compared to the current reference standard (i.e., transesophageal echocardiography—TEE) in patients aged <55 years with a cryptogenic acute ischemic stroke (AIS) or high‐risk (ABCD 2 score ≥4) transient ischemic attack (TIA), and to calculate the real life delay in detecting RLS by cTCD versus TEE in a tertiary care academic stroke center.MethodsConsecutive 16‐ to 54‐year‐old patients with AIS or high‐risk TIA underwent complete diagnostic workup which included, in case of undetermined etiology, cTCD and TEE. Sensitivity and specificity of cTCD, RLS characteristics, and median delay between the two tests were calculated.ResultsOf the 98 included patients, 52 (53%) had a cryptogenic cerebrovascular ischemic event, which displayed a 56% prevalence of RLS related to a patent foramen ovale (PFO) mainly with a high‐grade shunt. When comparing TCD with “bubble test” to TEE, sensitivity and specificity were both 100%. Median delays from symptom onset to examination were 2 (min–max 1–10) and 21 (min–max 1–60) days, respectively, for cTCD and TEE. No adverse event occurred during or after cTDC examination.ConclusionsTranscranial Doppler with “bubble test” appears as the best screening test for the detection of RLS in young and middle‐aged adults with cryptogenic acute cerebral ischemic events to select patients potentially suitable for closure procedure after TEE confirmation.

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Transcranial Doppler to detect right‐to‐left shunt in cryptogenic acute ischemic stroke

et al. 2018

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“…Considering the current guidelines, TEE would result in PFO closure in 40% of the patients of this cohort under the age of 60 years with PFO or PFO plus ASA. A number of studies (25)(26)(27) used transcranial Doppler ultrasound ("bubble-test") or TTE to detect PFO non-invasively. Transcranial Doppler ultrasound is highly sensitive and specific for the detection of a cardiac rightto-left shunt even in patients with negative TTE or TEE (26,27).…”

Section: Septal Anomaliesmentioning

confidence: 99%

“…A number of studies (25)(26)(27) used transcranial Doppler ultrasound ("bubble-test") or TTE to detect PFO non-invasively. Transcranial Doppler ultrasound is highly sensitive and specific for the detection of a cardiac rightto-left shunt even in patients with negative TTE or TEE (26,27). Thus, if TEE is only indicated for the search of PFO (i.e., in stroke patients ≤55 years without a suspicion of aortic atheroma, cardiac disease or endocarditis) it is dispensable in case of a negative "bubble test" or a negative TTE.…”

Section: Septal Anomaliesmentioning

confidence: 99%

Who Should Rather Undergo Transesophageal Echocardiography to Determine Stroke Etiology: Young or Elderly Stroke Patients?

Strecker

Günther²,

Harloff

2020

Front. Neurol.

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Introduction: The indication of transesophageal echocardiography (TEE) in acute stroke is unclear. Thus, we systematically studied the impact of TEE on determining stroke etiology and secondary prevention in patients of different age-groups with cryptogenic stroke.Methods: Four hundred and eighty five consecutive patients with acute retinal or cerebral ischemia were prospectively included and underwent routine stroke workup including TEE. Stroke etiology was identified according to the TOAST classification and patients were divided in those with determined and cryptogenic stroke etiology without TEE results. Then, the frequency of high- and potential-risk sources in TEE was evaluated in <55, 55–74, and ≥75 year-old patients with cryptogenic stroke etiology.Results: Without TEE, stroke etiology was cryptogenic in 329(67.8%) patients and TEE determined possible etiology in 158(48.4%) of them. In patients aged <55, 55–74, ≥75, TEE detected aortic arch plaques ≥4 mm thickness in 2(1.2%), 37(23.0%), and 33(40.2%) and plaques with superimposed thrombi in 0(0.0%), 5(3.1%), and 7(8.5%); left atrial appendage peak emptying flow velocity ≤30cm/s in 0(0.0%), 1(0.6%), and 2(2.4%), spontaneous echo contrast in 0(0.0%), 1(0.6%), and 6(7.3%), endocarditis in 0(0.0%), 0(0.0%), and 1(1.2%) and patent foramen ovale (PFO) plus atrial septum aneurysm (ASA) in 18(20.9%), 32(19.9%), and 14(17.1%), respectively. TEE changed secondary prevention in 16.4% of these patients following guidelines of 2010/11 and still 9.4% when applying the guidelines of 2020.Conclusions: TEE was highly valuable for determining stroke etiology and influenced individual secondary prevention based on available treatment guidelines and expert opinion in most cases. In young patients the impact of TEE was limited to the detection of septal anomalies. By contrast, in older patients TEE detected high numbers of complex aortic atheroma and potential indicators of paroxysmal atrial fibrillation.

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“…It was also found that TTE was more sensitive for PFO detection when investigating stroke patients compared to non-stroke patients, which suggests it may be more suited for the detection of larger PFOs, rather than smaller PFOs which tend to be associated with migraines. 43 While advocates of TCD believe it is superior to echocardiography, and indeed some individual studies support this view, 32,44 few studies have compared TTE and TCD head-tohead. Thus, it is difficult to compare techniques performed in cohorts of different patients.…”

Section: Comparison Of Different Imaging Techniquesmentioning

confidence: 99%

Review: Detection of patient foramen ovale using transcranial Doppler or standard echocardiography

Giessen

Wilson

Coffey

et al. 2020

Australas J Ultrason Med

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A patent foramen ovale (PFO) is a common remnant of fetal circulation present in up to 25% of the worldwide adult population. Paradoxical embolism occurs when venous blood crosses the PFO into the arterial system, bypassing the pulmonary circulation. This allows for the direct passage of microemboli into cerebral blood vessels, increasing the risk of cryptogenic stroke. This review investigates the current diagnostic procedures used to detect and grade a PFO, including transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE) and transcranial Doppler (TCD). Only a few studies have directly compared the use of TTE with TCD for PFO detection but several have compared TTE and TCD independently against the clinical gold standard TOE. Known pitfalls of TTE and TCD are also discussed, including the difficulty of differentiating between intracardiac shunts and intrapulmonary shunts. This review also discusses methods to optimise imaging, such as performing an adequate Valsalva manoeuvre, the role of abdominal compression and the choice of the injection site for the contrast agent and how these may increase the diagnostic success of detecting a right-to-left shunt when prompted by a clinician.

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Transcranial Doppler to Detect Right to Left Communication: Evaluation Versus Transesophageal Echocardiography in Real Life

Cited by 13 publications

References 25 publications

Transcranial Doppler to detect right‐to‐left shunt in cryptogenic acute ischemic stroke

Transcranial Doppler to detect right‐to‐left shunt in cryptogenic acute ischemic stroke

Who Should Rather Undergo Transesophageal Echocardiography to Determine Stroke Etiology: Young or Elderly Stroke Patients?

Review: Detection of patient foramen ovale using transcranial Doppler or standard echocardiography

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