Comparison of transcranial contrast Doppler sonography and transesophageal contrast echocardiography for the detection of patent foramen ovale in young stroke patients

Fp, Job; Eb, Ringelstein; Grafen, Y; Fa, Flachskampf; Doherty, Christopher; A, Stockmanns; Hanrath, Peter

doi:10.1016/0002-9149(94)90407-3

Cited by 195 publications

(129 citation statements)

References 18 publications

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“…(1) The appropriate timing of the VM in relation to the injection of the contrast medium is under debate. The injection of the contrast agent was performed before, 4,[11][12][13][14][15][16][17][18] during, 15,17,19 or after the VM. 15,20 In those studies in which the VM was performed after injection, the time delay between injection and VM was frequently not clearly specified in relation to the start or the end of injection.…”

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confidence: 99%

“…22 Furthermore, the question of whether the use of a diagnostic time window for MES appearance increases the specificity of the test without necessarily decreasing sensitivity is not yet resolved. 14,23,24 Time windows proposed between the intravenous injection of the contrast medium and its appearance in the MCAs are 6 heartbeats, 20 10 seconds, 20,21 15 seconds, 13 20 seconds, 24 22 seconds, 15 and 25 seconds. 11,14 A recent study described the necessity of including MES at least 20 to 25 seconds after the start of injection to achieve a high sensitivity; it may also be possible that no time window is necessary.…”

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confidence: 99%

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Contrast Transcranial Doppler Ultrasound in the Detection of Right-to-Left Shunts

Droste

Silling

Stypmann

et al. 2000

Stroke

107

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Background and Purpose-Cardiac right-to-left shunts can be identified by transesophageal echocardiography (TEE) and by transcranial Doppler ultrasound (TCD) with the use of contrast agents and a Valsalva maneuver (VM) as provocation procedure. Currently, data on the appropriate timing of the VM, the use of a diagnostic time window, and a threshold in contrast agent microbubbles detected are insufficient. Methods-Fifty-eight patients were investigated by both TEE and bilateral TCD of the middle cerebral artery. The following protocol with injections of 10 mL of the commercial galactose-based contrast agent Echovist was applied in a randomized way: (1) no VM, (2) VM for 5 seconds starting 2 seconds after the beginning of contrast injection, (3) VM for 5 seconds starting 5 seconds after the beginning of contrast injection, (4) VM for 5 seconds starting 8 seconds after the beginning of contrast injection, and (5) repetitive short VMs in between 2 and 13 seconds after the beginning of contrast injection. In addition to the single tests, we also tested the sensitivity and specificity of combined results of the tests with VM. Results-In 21 patients, a right-to-left shunt was demonstrated by TEE and contrast TCD (shunt positive). Twenty-one patients were negative in both investigations, no patient was positive on TEE and negative on TCD, and 16 patients were only positive on at least 1 TCD investigation but negative during TEE. Test 3 was the most appropriate test when combined with the results of 1 of the other tests with VM. The highest sensitivities were achieved with a diagnostic time window of 40 seconds and when the presence of a single microbubble was sufficient for the diagnosis of a shunt. Conclusions-TCD performed twice with 2 provocation maneuvers with Echovist is a sensitive method to identify TEE-proven cardiac right-to-left shunts. The VM should be performed for 5 seconds starting at 5 seconds after the beginning of contrast injection.

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confidence: 99%

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confidence: 99%

Contrast Transcranial Doppler Ultrasound in the Detection of Right-to-Left Shunts

Droste

Silling

Stypmann

et al. 2000

Stroke

107

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“…TCD has been demonstrated to have high sensitivity and specificity for detection of rightto-left shunting when compared to contrast transesophageal echocardiography and is superior to transthoracic echocardiography. [15][16][17][18][19][20][21][22] Transthoracic echocardiography (TTE) with agitated saline has decreased sensitivity of detecting an intracardiac shunt in OSA patients with elevated BMI and large body habitus secondary to limited acoustic windows. 13,21 Using passage of a guide wire across the atrial septum during cardiac catheterization with intracardiac echocardiography guidance as the standard for diagnosing a PFO, TCD has a 98% sensitivity for making the diagnosis of PFO.…”

Section: Methodsmentioning

confidence: 99%

“…TCD is limited by its inability to identify the location of the shunt; however, almost all right-toleft shunts are due to PFOs or small ASDs since other etiologies, such as large trans-pulmonary shunting from pulmonary AVMs, are rare (1% of TCD exams). [15][16][17][18][19][20] Compared with heart catheterization for PFO detection, TCD is more sensitive than TEE since there is a 10% false negative rate with TEE because patients cannot perform a Valsalva maneuver with a TEE probe down their esophagus. 20,[22][23][24] The patients in our study with OSA and PFO did not undergo PFO closure, which would be needed to evaluate a cause and effect relationship.…”

Section: Limitationsmentioning

confidence: 99%

Sleep Apnea in Patients with and without a Right-to-Left Shunt

Mojadidi

Bokhoor

Gevorgyan

et al. 2015

Journal of Clinical Sleep Medicine

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BRIEF SUMMARYCurrent Knowledge/Study Rationale: Right-to-left shunt (RLS) occurs more frequently in patients with sleep apnea, and may be involved in the pathophysiology of sleep apnea. In this observational study, we determined the prevalence of RLS among patients with sleep apnea and compared clinical characteristics and the results of sleep studies of patients with and without RLS. Study Impact: Patients with OSA and RLS have hypoxemia out of proportion to the observed respiratory disturbance, highlighting the likely role of RLS in the resultant nocturnal desaturation. Such observational studies support the hypothesis that the presence of a RLS from a PFO may exacerbate sleep apnea symptoms Objectives: To assess the presence of right-to-left shunting (RLS) in patients with obstructive sleep apnea (OSA), and compare clinical characteristics and parameters of the sleep studies of patients with and without RLS. Background: The most common cause of RLS is due to intermittent fl ow through a patent foramen ovale (PFO). PFO occurs more frequently in patients with OSA and may be involved in the exacerbation of OSA. Methods: Patients with an abnormal polysomnogram seen at UCLA-Santa Monica Sleep Medicine Clinic were enrolled. A diagnosis of RLS was made using a transcranial Doppler (TCD) bubble study. Gender and age-matched controls were drawn from patients referred for cardiac catheterization who underwent a TCD. The frequency of RLS in OSA patients and the controls was evaluated. Clinical characteristics and polysomnogram parameters were compared between OSA patients with and without a RLS. Results: A total of 100 OSA patients and 200 controls participated in the study. The prevalence of RLS was higher in patients with OSA compared to the control group (42% versus 19%; p < 0.0001). Patients with OSA and a RLS had a lower apnea-hypopnea index (AHI), less obstructive apnea, and fewer hypopnea episodes than patients with OSA without a RLS. The baseline and nadir SpO 2 were similar in both groups and did not correlate with the level of RLS assessed by TCD. The degree of desaturation for a given respiratory disturbance, as measured by oxygen desaturation index (ODI)/AHI ratio, was higher in OSA patients with RLS versus OSA patients without RLS (0.85 ± 0.07 versus 0.68 ± 0.04; p < 0.0001). Conclusion: RLS, most commonly due to a PFO, occurs 2.2 times more frequently in OSA patients compared to a control population that was matched for age and gender. The severity of sleep apnea is not greater in OSA patients who have a PFO. However, patients with OSA and a PFO are more likely to become symptomatic at a younger age with an equivalent decrease in nocturnal SpO 2 , and have greater arterial desaturation in proportion to the frequency of respiratory disturbances. Keywords: sleep apnea, patent foramen ovale, right-to-left shunt Citation: Mojadidi MK, Bokhoor PI, Gevorgyan R, Noureddin N, MacLellan WC, Wen E, Aysola R, Tobis JM. Sleep apnea in patients with and without a right-to-left shunt. J Clin Sleep Med 2015;11(11):1299 -...

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“…The rate of detection of RLS in TCD study might be inferior to that on TEE study, because the sensitivity of TCD study in detecting RLS is less than that of TEE study. 16 Second, we were unable to perform peripheral venous ultrasound to detect DVT in all patients.…”

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confidence: 99%