Right‐to‐left shunt detection using transforaminal insonation of the basilar artery

Abstract

BACKGROUND AND PURPOSE Investigation for patent foramen ovale (PFO) is warranted in patients with cryptogenic stroke (CS), as PFO closure is recommended in select CS patients for secondary stroke prevention. Transcranial Doppler (TCD) is noninvasive and has high sensitivity for PFO screening. However, 10% of the population has insufficient temporal bone windows to perform standard TCD monitoring of the middle cerebral arteries (MCAs). Prior reports showed similar diagnostic accuracy between the basilar artery and MCAs insonation. Our objective was to assess the accuracy of transforaminal insonation of the basilar artery (TIBA) in diagnosis of right‐to‐left shunt (RLS) in patients with inadequate temporal windows. METHODS We performed a retrospective, single‐center, observational study of TIBA in patients with CS and inadequate temporal windows. We compared the PFO screening accuracy using TIBA versus echocardiogram, either transthoracic (TTE) or transesophageal echocardiogram (TEE). RESULTS Sixteen females and four males were included (mean age 63.2). All patients underwent TTE, 10 (50%) underwent gold‐standard TEE. Nine patients had positive PFO with both TCD and echocardiogram. Two patients with negative echocardiogram had TCD‐positive shunt. Three patients had PFO present on echocardiogram, whereas TCD was negative. Six patients had absent shunt with both TCD and echocardiogram. The sensitivity and specificity of TIBA for RLS detection were 75%, positive predictive value 82%, and negative predictive value 67%. CONCLUSION PFO screening accuracy using TIBA was 75%. Prospective evaluation of CS patients with TIBA and comparison to the gold‐standard TEE should be performed to further guide clinical practice.

Right-to-Left Shunt Evaluation in Cardiac Patent Foramen Ovale Using Bubble Contrast Transcranial Color-Coded Doppler: A Cryptogenic Stroke Case

“…The primary method for diagnosing RLS in PFOs relies on ultrasound examinations that provide real-time insights. Transesophageal echocardiography (TEE) is considered the gold standard for evaluating PFOs [7]. TEE facilitates the morphological assessment of PFO Healthcare 2023, 11, 2655 2 of 10 and has a high sensitivity of 89.2% and specificity of 91.4% in detecting RLS [8].…”