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

Palazzo, Paola; Ingrand, Pierre; Agius, Pierre; Chaidi, R. Belhadj; Neau, Jean‐Philippe

doi:10.1002/brb3.1091

Cited by 26 publications

(14 citation statements)

References 23 publications

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“…Cumulatively, PFO was documented in 186 of 1,267 (14.7, 95% CI = 12.8-16.7) healthy subjects/controls, in 66 of 131 (50.4, 95% CI = 41.9-58.8) patients with CE, and in 11 of 125 (8.8, 95% CI = 4.8-15.2) patients with non-CE. In our review, we included 12 TCD studies (58)(59)(60)(61)(62)(63)(64)(65)(66)(67)(68)(69). Three studies were conducted in migraineurs compared to a healthy population (59)(60)(61), and nine studies reported data from patients with cerebrovascular events, of which five studies (63-67) also included TIAs (20-75% of the total events).…”

Section: Resultsmentioning

confidence: 99%

Epidemiology of Patent Foramen Ovale in General Population and in Stroke Patients: A Narrative Review

et al. 2020

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Introduction: Percutaneous closure of patent foramen ovale (PFO) in selected patients with cryptogenic cerebrovascular ischemic events (CEs) decreases the risk of recurrent stroke; however, optimal patient selection criteria are still under investigation. Candidates for PFO closure are usually selected from the pool of CE patients with a high risk of Paradoxical Embolism (RoPE) score. The RoPE score calculates the probability that PFO is causally related to stroke, based on PFO prevalence in patients with CE compared with that in healthy subjects. The latter has been set at 25% based on the average of autopsy and transesophageal echocardiography (TEE) studies. Methods: We conducted a comprehensive review of studies investigating PFO prevalence in general population and in patients with CE and non-CE using autopsy, TEE, transcranial Doppler (TCD) or transthoracic echocardiography (TTE). Studies were excluded if they (1) reported data from referred subjects with underlying cerebrovascular disease or (2) did not specify etiologically the events. Results: In healthy/control subjects, PFO prevalence was 24.2% (1,872/7,747) in autopsy studies, 23.7% (325/1,369) in TEE, 31.3% (111/355) in TCD, and 14.7% (186/1,267) in TTE studies. All diagnostic modalities included PFO prevalence was higher in CE compared with healthy/control population [odds ratio (OR) = 3.1, 95% confidence interval (CI) = 2.5-3.8] and compared with non-CE (OR = 2.3, 95% CI = 2.0-2.6). In patients with CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (48.9 vs. 27.3%, p < 0.0001, OR = 2.6 with 95% CI = 2.0-3.3) or TCD (58.1 vs. 41%, OR = 1.9, 95% CI = 1.6-2.5), but not TTE (53.3 vs. 37.5%, p = 0.16). Regarding non-CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (20 vs. 12.9%, OR = 1.7, 95% CI = 1.0-2.8) but not TTE (10.4 vs. 7.8%, p = 0.75) or TCD (22.8 vs. 20.1%, p = 0.56). Conclusions: Given the limitations of autopsy and TEE studies, there is good reason not to take a fixed 25% PFO prevalence for granted. The estimation of degree of causality may be underestimated or overestimated in populations with PFO prevalence significantly lower or higher than the established. Given the high sensitivity, non-invasive nature, low cost, and repeatability of TCD, future large-scale TCD-based studies should investigate potential heterogeneity in PFO prevalence in different healthy racial/ethnic populations.

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Section: Resultsmentioning

confidence: 99%

Epidemiology of Patent Foramen Ovale in General Population and in Stroke Patients: A Narrative Review

et al. 2020

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“…However, transesophageal examination is very often a great discomfort for the patient. It is also emphasized that some venous-arterial shunts (RLS -right -left shunts) may be overlooked in TEE due to the difficulties in performing the Valsalva maneuvre by patients [11,14]. Transesophageal echocardiography is an invasive examination, carrying a risk of potentially dangerous complications.…”

Section: Introductionmentioning

confidence: 99%

“…An alternative to transesophageal echocardiography for detecting a venous-arterial shunt, is contrast enhanced ultrasound Doppler examination of intracranial arteries and arteries supplying the head ('blind doppler', Transcranial Doppler -TCD), which as a cheap, noninvasive and safe method characterized by very high sensitivity and specificity (97% -100% and 93-98% respectively) [11,14,16], and which may significantly improve the detection of cases of PFO with venous-arterial shunt and enable screening of divers and candidates for divers.…”

Section: Introductionmentioning

confidence: 99%

“…Devices for ultrasound Doppler examination of arteries supplying the head, as well as intracranial arteries ('blind doppler', Transcranial Doppler -TCD) are widely used in Stroke Units to diagnose patients with ischaemic stroke. The first intracranial arterial flow tests were performed in 1982 and since then TCD has been proven as a useful method of detecting vascular diseases of the nervous system, including the detection of PFO [11,14,16,17].…”

Section: Introductionmentioning

confidence: 99%

“…In the year 2000, a standard for the detection of a venous-arterial shunt by Doppler sonography was established [18], which has caused these studies to be highly sensitive and specific, to a degree comparable to transesophageal echocardiography [11,14,16].…”

Section: Introductionmentioning

confidence: 99%

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

Dziewiatowski¹,

Siermontowski

2019

Polish Hyperbaric Research

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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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Transcranial Doppler as a Primary Screening Tool for Detecting Right‐to‐Left Shunt in Cryptogenic Stroke Patients?

Sasannejad,

Khosravani,

Ziaei Moghaddam

et al. 2024

Brain and Behavior

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BackgroundCryptogenic stroke (CS), a subtype of ischemic stroke with undetermined etiology, accounts for approximately 25% of the cases. Patent foramen ovale (PFO) is an important potential cause of CS via paradoxical embolism. While transesophageal echocardiography (TEE) is the current gold standard for PFO detection, transcranial Doppler (TCD) ultrasound offers a noninvasive alternative with potential advantages in sensitivity for right‐to‐left shunt (RLS) detection. This study's main goal is to evaluate the diagnostic performance of TCD compared to TEE for PFO detection in CS patients.MethodsWe prospectively enrolled 110 patients aged 18–65 years with confirmed CS from 2020 to 2024. All underwent TCD screening for RLS using a standardized protocol. Subsequently, they were categorized based on a simplified version of the Spencer Logarithmic Scale, followed by confirmatory TEE. Clinical characteristics, imaging findings, TCD results, and indications for PFO closure were analyzed.ResultsThe mean age of the cohort was 45 years, with 58.2% being males. TEE identified PFO in 44.5% (49/110) of subjects. TCD accurately detected RLS in 42 of the 49 PFO cases (85.7%) confirmed by TEE. For PFO detection, TCD demonstrated a sensitivity of 85.4%, specificity of 88.5%, PPV of 85.4%, and Youden's index of 0.73. Notably, of the seven PFO cases missed by TCD, none received percutaneous closure based on clinical criteria.ConclusionsTCD exhibited high diagnostic accuracy for detecting high‐risk PFO in patients with CS when compared to the gold‐standard TEE. As a noninvasive modality, TCD may serve as an effective screening tool to identify CS patients who could potentially benefit from confirmatory TEE and subsequent PFO closure intervention. The findings support the use of TCD as a screening tool to triage CS patients for confirmatory TEE and potential PFO closure.

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

Cited by 26 publications

References 23 publications

Epidemiology of Patent Foramen Ovale in General Population and in Stroke Patients: A Narrative Review

Epidemiology of Patent Foramen Ovale in General Population and in Stroke Patients: A Narrative Review

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

Transcranial Doppler as a Primary Screening Tool for Detecting Right‐to‐Left Shunt in Cryptogenic Stroke Patients?

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