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Background:
Persistent foramen ovale (PFO) is considered a cause of cryptogenic stroke and a risk factor for neurological events in young patients. The reference standard for identifying a PFO is contrast-enhanced transesophageal echocardiography (TEE).The goal of this study was to evaluate the feasibility of transcranial color Doppler (TCD) and i...
Context in source publication
Context 1
... feasibility of both methods was 100%. Shunts con- firmed by both methods (TCD and TEE) were found in: 78.4% of patients with cryptogenic stroke, in 48.6% of patients with TIA, and only in 10.4% of patients with mi- graine without aura (Table 2). Considering TEE as the gold standard technique, TCD was able to identify 200 (91.3%) of the 241 patients with PFO. ...
Similar publications
Objectives:
To access the distinct values of contrast transcranial Doppler (cTCD), contrast transthoracic echocardiography (cTTE), and contrast transesophageal echocardiography (cTEE) in the diagnosis of right-to-left shunt (RLS) due to patent foramen ovale (PFO) and to define the most practical strategy for the diagnosis of PFO.
Methods:
102 pa...
The comparative severity of patent foramen ovale (PFO)-related stroke in patients without atrial fibrillation (AF) and AF-related stroke in patients without PFO is unknown. Therefore, we compared the severity of PFO-related stroke and AF-related stroke. Twenty-six patients who underwent transesophageal echocardiography (TEE) were diagnosed with car...
Patent foramen ovale (PFO) is a remnant of the fetal circulation exist in 20% of the general population. The purpose of our study was to compare of transthoracic echocardiography (TTE) and contrast-transcranial Doppler sonography (c-TCD) in the diagnosis and quantification of PFO with or without the Valsalva maneuver (VM).
We studied 106 patients w...
Background
Patent foramen ovale (PFO) is a risk factor for cryptogenic stroke (CS), and interventional therapy for PFO can reduce the recurrence rate of CS. However, interventional therapies are primarily guided by X-ray imaging, and regular postsurgical follow-up with transthoracic ultrasound foaming test (UFT) is rarely performed. Thus, this stud...
Objective
Traditional metal alloy occluders for the closure of patent foramen ovale (PFO) may be associated with some potential complications, and may restrict the trans-septal access to the left atrium for future treatment of left-sided heart disease. Increasing attention has been paid to novel biodegradable occluders (NBOs) to achieve PFO closure...
Citations
... Transcranial Doppler (TCD) is another method that uses a low-frequency probe to assess cerebral blood vessels through the temporal acoustic window. TCD-based RLS assessment involves injecting microbubbles of agitated saline contrast into venous blood and detecting high-intensity transient signals (HITS) in cerebral blood flow as the microbubbles travel into the arterial system [10,11]. TCD exhibits exceptional sensitivity (95%) and specificity (92%) in detecting RLS. ...
Traditional diagnosis of patent foramen ovale (PFO) in the heart has involved the use of transcranial Doppler (TCD). However, TCD is essentially a blind test that cannot directly visualize the location of blood vessels. Since TCD relies on qualitative assessments by examiners, there is room for errors, such as misalignment of the ultrasound’s angle of incidence with the actual blood vessels. This limitation affects the reproducibility and consistency of the examination. In this study, we presented an alternative approach for assessing right-to-left shunt (RLS) associated with PFO using contrast transcranial color-coded Doppler (C-TCCD) with bubble contrast. The patient under consideration had been diagnosed with an ischemic stroke through imaging, but the subsequent cardiac work-up failed to determine the cause. Employing C-TCCD for RLS screening revealed a confirmed RLS of Spencer’s three grades. Subsequently, transesophageal echocardiography (TEE) was conducted to evaluate PFO risk factors, confirming an 8 mm PFO size, a 21 mm tunnel length, a hypermobile interatrial septum, and persistent RLS. The calculated high-risk PFO score was 4 points, categorizing it as a very high risk PFO. This case underscores the importance of C-TCCD screening in detecting RLS associated with PFO, especially in cryptogenic stroke patients, when identifying the underlying cause of ischemic stroke becomes challenging.
... Transcranial Doppler (TCD) is another method that uses a low-frequency probe to assess cerebral blood vessels through the temporal acoustic window. TCD-based RLS assessment involves injecting microbubbles of agitated saline contrast into venous blood and detecting high-intensity transient signals (HITS) in cerebral blood flow as the microbubbles travel into the arterial system [10,11]. TCD exhibits exceptional sensitivity (95%) and specificity (92%) in detecting RLS. ...
Traditional diagnosis of patent foramen ovale (PFO) in the heart has involved the use of transcranial doppler (TCD). However, TCD is essentially a blind test that cannot directly visualize the location of blood vessels. Since TCD relies on qualitative assessments by examiners, there is room for errors, such as misalignment of the ultrasound's angle of incidence with the actual blood vessels. This limitation affects the reproducibility and consistency of the examination. In this study, we presented an alternative approach for assessing right-to-left shunt (RLS) associated with PFO using contrast transcranial color-coded doppler (C-TCCD) with bubble contrast. The patient under consideration had been diagnosed with an ischemic stroke through imaging, but the subsequent cardiac work-up failed to determine the cause. Employing C-TCCD for RLS screening revealed a confirmed RLS of Spencer’s three grades. Subsequently, transesophageal echocardiography (TEE) was conducted to evaluate PFO risk factors, confirming an 8 mm PFO size, a 21 mm tunnel length, a hypermobile interatrial septum, and persistent RLS. The calculated high-risk PFO score was 4 points, categorizing it as a very high-risk PFO. This case underscores the importance of C-TCCD screening in detecting RLS associated with PFO, especially in cryptogenic stroke patients when identifying the underlying cause of ischemic stroke becomes challenging.
... To prove the presence of left-sided microbubbles (and thus a right-to-left shunt), bubbles can be detected by ultrasound within the middle cerebral artery using transcranial Doppler imaging. 21 Visualization of microbubbles within the cerebral circulation following intravenous ASC injection is highly specific and sensitive for right-to-left shunt, 21 and yet not associated with cerebral air embolism causing stroke. 22 ...
... To prove the presence of left-sided microbubbles (and thus a right-to-left shunt), bubbles can be detected by ultrasound within the middle cerebral artery using transcranial Doppler imaging. 21 Visualization of microbubbles within the cerebral circulation following intravenous ASC injection is highly specific and sensitive for right-to-left shunt, 21 and yet not associated with cerebral air embolism causing stroke. 22 ...
The use of agitated saline contrast (ASC) during echocardiographic examinations is a well-established practice, most commonly performed to identify atrial septal abnormalities in the context of stroke. In the intensive care unit, this technique may be employed to identify anatomic right-to-left shunts (either intracardiac or transpulmonary) that may be contributing to hypoxemic respiratory failure. This narrative review will describe the technique of ASC injection, summarize clinical scenarios where it may be useful, and review the strengths and limitations of the tool.
... We performed a retrospective cohort study at a tertiary stroke center. Between January 2014 and December 2020, all consecutive patients with ischemic stroke or TIA who had undergone a non-invasive TCD bubble study with agitated saline were screened for inclusion [19,20]. Patients were included if they were at least 18 years old and had been diagnosed with cryptogenic stroke (stroke of unknown origin) according to the TOAST classification (one cause, more than one cause, no cause after work-up, and no cause with extensive or complete work-up) [21]. ...
Introduction:
Patent foramen ovale (PFO) is a potential source of cardiac embolism in cryptogenic ischemic stroke, but it may also be incidental. Right-to-left shunt (RLS) size may predict PFO-related stroke, but results have been controversial. In this cohort study of medically-managed PFO patients with cryptogenic stroke, we aimed to investigate the association of shunt size with recurrent stroke, mortality, newly detected atrial fibrillation (AF), and to identify predictors of recurrent stroke.
Methods:
Patients with cryptogenic stroke who screened positive for a RLS using a transcranial Doppler bubble study were included. Patients who underwent PFO closure were excluded. Subjects were divided into two groups: small (Spencer Grade 1, 2, or 3; n = 135) and large (Spencer Grade 4 or 5; n = 99) shunts. The primary outcome was risk of recurrent stroke, and the secondary outcomes were all-cause mortality and newly detected AF.
Results:
The study cohort included 234 cryptogenic stroke patients with medically-managed PFO. The mean age was 50.5 years, and 31.2% were female. The median period of follow-up was 348 (IQR 147-1096) days. The rate of recurrent ischemic stroke was higher in patients with large shunts than in those with small shunts (8.1% vs. 2.2%, p = 0.036). Multivariate analyses revealed that a large shunt was significantly associated with an increased risk of recurrent ischemic stroke [aOR 4.09 (95% CI 1.04-16.0), p = 0.043].
Conclusions:
In our cohort of cryptogenic stroke patients with medically managed PFOs, those with large shunts were at a higher risk of recurrent stroke events, independently of RoPE score and left atrium diameter.
... Not all patients had a confirmatory diagnosis by TEE, which is the gold standard evaluation, and therefore, PASCAL classification could not be reliably calculated in this study. Nonetheless, TCD bubble study has been shown to be an appropriate screening modality for PFOs with good sensitivity and specificity [38]. ...
Introduction:
A patent foramen ovale (PFO) may coexist with other potential embolic sources (PESs) in patients with embolic stroke of undetermined source (ESUS), leading to difficulty in attributing the stroke to either the PFO or other PESs. We aimed to investigate the prevalence and predictors of concomitant PESs in ESUS patients with PFOs.
Methods:
A retrospective cohort study was conducted in a tertiary stroke centre. Consecutive patients with ESUS and a concomitant PFO admitted between 2012 and 2021 were included in the study. Baseline characteristics and investigations as a part of stroke workup including echocardiographic and neuroimaging data were collected. PESs were adjudicated by 2 independent neurologists after reviewing the relevant workup.
Results:
Out of 1,487 ESUS patients, a total of 309 patients who had a concomitant PFO with mean age of 48.8 ± 13.2 years were identified during the study period. The median Risk of Paradoxical Embolism (RoPE) score for the study cohort was 6 (IQR 5-7.5). Of the 309 patients, 154 (49.8%) only had PFO, 105 (34.0%) patients had 1 other PES, 34 (11.0%) had 2 PES, and 16 (5.2%) had 3 or more PES. The most common PESs were atrial cardiopathy (23.9%), left ventricular dysfunction (22.0%), and cardiac valve disease (12.9%). The presence of additional PESs was associated with age ≥60 years (p < 0.001), RoPE score ≤6 (p ≤0.001), and the presence of comorbidities including diabetes mellitus (p = 0.004), hypertension (p≤ 0.001), and ischaemic heart disease (p = 0.011).
Conclusion:
A large proportion of ESUS patients with PFOs had concomitant PESs. The presence of concomitant PESs was associated with older age and a lower RoPE score. Further, large cohort studies are warranted to investigate the significance of the PES and their overlap with PFOs in ESUS.
... Intracardiac echocardiography (ICE) can guide percutaneous PFO closure. 54 Specifically, the absence of right-to-left shunting on ICE immediately after the deployment of the closure device confirms that the procedure was successful. 55 Transcranial Doppler is up to 30% more sensitive than ICE for detecting right-to-left shunting during surgery after deployment of the device. ...
Air embolic signals detected in the intracranial arteries using transcranial Doppler after intravenous injection of agitated saline bubbles indicate right-to-left cardiac shunting. They prove that emboli from venous sites can bypass the lungs and flow to the intracranial arteries. The Valsalva maneuver immediately after an intravenous injection of agitated saline bubbles helps the air bubbles pass through the shunt. If the air embolic signal appears in the intracranial arteries without the Valsalva maneuver, the shunting is highly significant to the etiology of embolism. Transcranial Doppler to detect air embolic signals after intravenous injection of agitated saline bubbles may not be mandatory to diagnose and treat patent foramen ovale; however, as with echocardiography, transcranial Doppler is considered a noninvasive, convenient, and low-cost investigation. The test should be helpful to confirm the significance of the corresponding patent foramen ovale.
... Even though transcranial Doppler echocardiography has been utilized for the noninvasive diagnosis of a right-to-left shunt by detecting microbubble signals in the middle cerebral artery, the test does not distinguish intracardiac and extracardiac shunts. [23][24][25][26] Intracardiac echocardiography (ICE) is primarily utilized for procedural assistance during cardiac catheterization. [27] ...
A patent foramen ovale (PFO) is a frequent incidental finding during echocardiography in otherwise healthy children. In most healthy children with a diagnosis of isolated incidental PFO, no further follow-up or intervention is necessary. In some children, PFO is associated with certain clinical syndromes such as cryptogenic stroke, decompression sickness, migraine, and platypnea–orthodeoxia syndrome. This review discusses PFO anatomy, diagnostic imaging, PFO-associated clinical situations, management options, and the role of PFO in certain congenital heart disease. This review also highlights the current deficiency of pediatric data guiding management of these uncommon but important PFO-associated conditions. Future multicenter randomized controlled studies are necessary to guide the management of these unique and challenging PFO-associated conditions.
... PFO was diagnosed by the bubble test on TCD [5]. TCD was done according to the Consensus Conference of Venice15 by one of two experienced operators. ...
Background
The aim of this study was to develop a screening score system of non-contrast transthoracic echocardiography (TTE) for patent foramen ovale (PFO) in patients with embolic stroke of undetermined source (ESUS).
Methods
We performed a retrospective analysis of 218 consecutive patients with a recent ESUS from 2015 to 2018, who received TTE and transcranial Doppler (TCD) as routine examinations. PFO was diagnosed by the bubble test of TCD. Significant differences of the non-contrast TTE findings and patient characteristics between PFO group and non-PFO group were selected into a score.
Results
PFO was diagnosed in 35.8% (78/218) of the patients. Compared with non-PFO group, a larger median aortic root diameter (ARd) (34 mm vs. 32 mm, p = 0.005), a lower median peak E wave velocity (Em) (61.5 cm/s vs. 68 cm/s, p = 0.005) and a lower incidence rate of mitral regurgitation (34.6% vs. 50.7%, p = 0.022) were seen in PFO group. ARd>33 mm and Em < 72 cm/s were the best thresholds to predict PFO in ROC analysis. A four-point score system (MEAD) including TTE criteria (including ARd>33 mm, Em < 72 cm/s and without mitral regurgitation) and no history of diabetes predicted PFO with an area under curve of 0.67 (95%CI 0.57–0.72, p < 0.001). MEAD score ≥ 3 was the best threshold to predict PFO with an accuracy of 0.64 (95% CI 0.57–0.7), a sensitivity of 0.65 (95% CI 0.53–0.75) and a specificity of 0.63 (95% CI 0.55–0.71).
Conclusion
The MEAD score measured with non-contrast TTE can be used to select patients for bubble test of TCD to increase the diagnostic yield of PFO after ESUS.
... PFOs, suggesting that use of TEE may not provide the highest sensitivity for RLS detection [30]. At present, c-TCD is the most commonly used method for detecting RLS clinically, including intracardiac and extracardiac RLS [14]. ...
Background:
Cardiogenic embolism caused by patent foramen ovale (PFO) is a common etiology of cryptogenic stroke (CS), particularly in young and middle-aged patients. Studies about right-to-left shunt (RLS) detection using contrast-enhanced transcranial Doppler (c-TCD) are numerous. According to the time phase and number of microbubbles detected on c-TCD, RLS can be classified and graded. We hypothesized that the characteristics of an infarction lesion on diffusion-weighted imaging differs when combining the type and grade of RLS on c-TCD in patients with PFO-related CS.
Aim:
To explore the characteristics of infarction lesions on diffusion-weighted imaging when combining the RLS type and grade determined by c-TCD.
Methods:
We retrospectively evaluated CS patients from August 2015 to December 2019 at a tertiary hospital. In total, 111 PFO-related CS patients were divided according to whether RLS was permanent (microbubbles detected both at resting state and after the Valsalva maneuver) or latent (microbubbles detected only after the Valsalva maneuver) on c-TCD. Each group was subdivided into small, mild and large RLS according to the grade of shunt on c-TCD. A normal control group was composed of 33 patients who suffered from simple dizziness. Intragroup and intergroup differences were analyzed in terms of clinical, laboratory and diffusion-weighted imaging lesion characteristics. The correlation between RLS grade evaluated by c-TCD and size of PFO determined by transesophageal echocardiography were also analyzed.
Results:
In 111 patients with PFO-related CS, 68 had permanent RLS and 43 had latent RLS. Clinical characteristics and laboratory tests were not significantly different among the permanent RLS, latent RLS and normal control groups. The proportion of patients with multiple territory lesions in the permanent RLS group (50%) was larger than that in the latent RLS group (27.91%; P = 0.021). Posterior circulation was more likely to be affected in the latent RLS group than in the permanent RLS group (30.23% vs 8.82%, P = 0.004). Permanent-large and latent-large RLS were both more likely to be related to multiple (P trend = 0.017 and 0.009, respectively), small (P trend = 0.035 and 0.006, respectively) and cortical (P trend = 0.031 and 0.033, respectively) lesions. The grade of RLS evaluated by c-TCD was correlated to the size of PFO determined by transesophageal echocardiography (r = 0.758, P < 0.001).
Conclusion:
Distribution of the infarct suggested the possible type of RLS. Multiple, small and cortical infarcts suggest large RLS induced by a large PFO.
... During TCD studies, micro-embolic signals [micro-bubbles] in the cerebral artery are registered. The study is considered positive if at least 1 micro-embolic signal is recorded during a window period of 25-40 s after the injection of agitated saline [15,16]. Thus, when the heart rate is 60 beats per minute, 25-40 cardiac cycles are analyzed by TCD for the presence of micro-embolic signals and not only 3-6 cardiac cycles as required by echocardiography. ...
... This assessment has recently been criticized [18]: when 10 micro-bubbles were used as an embolic cutoff, specificity of TCD was higher than when one micro-bubble was used as a cutoff without significant changes in sensitivity. [15,16]. TCD is more sensitive than echocardiography [19], probably because it analyzes many cardiac cycles versus only one frame used in echocardiography. ...
Accurate diagnosis of patent foramen ovale (PFO) and grading of right-to-left shunt severity by the standard method of transthoracic or transesophageal echocardiography (TEE) with bubble injection is often challenging. We proposed the novel Maximum Intensity T-Projection (MIP) Imaging method as a complementary or alternative approach for simplified diagnosis and grading of PFO. MIP Imaging represents the superimposition of all frames of an echocardiographic video onto one image. Thus, all bubbles passing from right to left atrium are represented in this single image. Diagnosis and quantification of PFO by MIP Images were compared to those obtained by standard echocardiographic methods, using the same echocardiography video loops. We applied the MIP Imaging approach to 122 echo examinations (75% of them TEE studies), performed to rule out PFOs. The average time needed to manually analyze video loops taken during bubble injection was 102 ± 52 s vs. less than 1 s using the MIP Imaging method. There was good concordance between the conventional echo method and MIP Imaging in the diagnosis and quantification of PFOs. MIP Imaging for diagnosis and quantification of PFOs was much less time consuming than the classical method and at least as accurate as the classical method. Thus MIP Imaging may be used initially as an adjunct method for PFO diagnosis and quantification and may eventually replace the classical method.
