Cohort study of multiple brain lesions in sport divers: role of a patent foramen ovale

Knauth, Michael; Ries, Stefan; Pohimann, Stefan; Kerby, Tina; Forsting, Michael; Daffertshofer, Michael; Hennerici, Michael G.; Sartor, Klaus

doi:10.1136/bmj.314.7082.701

Cited by 192 publications

(126 citation statements)

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“…6 In a seminal study, transcranial Doppler ultrasonography detected a right-to-left shunt in all divers with multiple brain lesions. 7 A foramen ovale no doubt accounted for most of these cases. A comparative investigation regarding brain lesions and the presence of a foramen ovale in sport divers and non-diving controls showed that brain lesions were more common in individuals with a foramen ovale, although divers had more brain lesions than non-divers, irrespective of the presence of a PFO.…”

Section: Decompression Illness In Diversmentioning

confidence: 99%

Contemporary Management of Patent Foramen Ovale

2003

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Section: Decompression Illness In Diversmentioning

confidence: 99%

Contemporary Management of Patent Foramen Ovale

2003

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“…The application of VM was standardized for c-TCD RLS diagnosis at an international consensus meeting 26 and more recently by Droste et al 24 However, the importance of the VM duration according to strain pressure is not established for the RLS assessment. Consid-ering the positive relationship between the RLS and the aforementioned disorders 5,6,10,[12][13][14][15][16][17][18][19][20][21][22][23] and taking into account that the criterion of large RLS may be used in making treatment decisions in patients with PFO, 20,22 we therefore hypothesized that control of VM criteria in terms of duration and strain pressure might improve c-TCD validity. The degree of RLS can also be estimated by a totally independent method, ie, by measuring arterial blood gas (ABG) while the subject is breathing pure oxygen.…”

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Controlled Contrast Transcranial Doppler and Arterial Blood Gas Analysis to Quantify Shunt Through Patent Foramen Ovale

Devuyst

Piechowski-Jóźwiak

Karapanayiotides

et al. 2004

Stroke

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Background and Purpose-A right-to-left shunt can be identified by contrast transcranial Doppler ultrasonography (c-TCD) at rest and/or after a Valsalva maneuver (VM) or by arterial blood gas (ABG) measurement. We assessed the influence of controlled strain pressures and durations during VM on the right-to-left passage of microbubbles, on which depends the shunt classification by c-TCD, and correlated it with the right-to-left shunt evaluation by ABG measurements in stroke patients with patent foramen ovale (PFO). Methods-We evaluated 40 stroke patients with transesophageal echocardiography-documented PFO. The microbubbles were recorded with TCD at rest and after 4 different VM conditions with controlled duration and target strain pressures (duration in seconds and pressure in cm H 2 O, respectively): V5-20, V10-20, V5-40, and V10-40. The ABG analysis was performed after pure oxygen breathing in 34 patients, and the shunt was calculated as percentage of cardiac output. Results-Among all VM conditions, V5-40 and V10-40 yielded the greatest median number of microbubbles (84 and 95, respectively; PϽ0.01). A significantly larger number of microbubbles were detected in V5-40 than in V5-20 (PϽ0.001) and in V10-40 than in V10-20 (PϽ0.01). ABG was not sensitive enough to detect a shunt in 31 patients. Conclusions-The increase of VM expiratory pressure magnifies the number of microbubbles irrespective of the strain duration. Because the right-to-left shunt classification in PFO is based on the number of microbubbles, a controlled VM pressure is advised for a reproducible shunt assessment. The ABG measurement is not sensitive enough for shunt assessment in stroke patients with PFO. Key Words: foramen ovale, patent Ⅲ oxygen Ⅲ ultrasonography, Doppler, transcranial Ⅲ Valsalva maneuver T he patent foramen ovale (PFO) with or without coexistent atrial septal aneurysm is generally considered to be associated with brain disorders, including first-ever ischemic stroke in young patients, 1,2 cryptogenic stroke, 3,4 migraine, 4 -6 and cerebral decompression sickness in scuba divers. 7,8 Some authors do not confirm the association between isolated PFO and increased risk of ischemic stroke 9 or recurrent stroke. 4,10 The size of PFO and the degree of right-to-left cardiac shunt (RLS) in these disorders are debated. 4,10 The presence of large PFO and high-degree RLS was demonstrated to increase the risk of cryptogenic stroke, 10 -13 recurrent stroke, 14 -16 the number of silent ischemic brain lesions in divers, 16 migraine with aura, 5,6,18 and cerebral decompression sickness. 19 Other studies show that either percutaneous or surgical closure of PFO decreases the number of recurrent ischemic strokes, 20,21 improves migraine symptoms, 22 and decreases the number of decompression cerebral ischemic events 23 and support the positive relation between highdegree RLS and the aforementioned pathologies.Contrast transcranial Doppler ultrasonography (c-TCD) is a complementary method to contrast-enhanced transesophageal echocardiography (c-T...

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“…Reul and colleagues (4) found 80% of all brain lesions in a subgroup of 27% of divers, possibly those with patent foramen ovale who had paradoxical arterial gas embolism during decompression (4). Knauth and coworkers (5) used transcranial Doppler ultrasonography to detect a rightto-left shunt in 87 sport divers; they reported that multiple brain lesions on magnetic resonance imaging (MRI) occurred exclusively in those with a large rightto-left shunt, which was presumed to be a patent foramen ovale (5). Detection of intravenously injected echocontrast bubbles in the cerebral vasculature is not specific for a patent foramen ovale; moreover, compared with transesophageal echocardiography, detection of these bubbles has been found to be only 68% sensitive in detecting a patent foramen ovale (6).…”

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confidence: 99%