Transcranial Doppler versus transthoracic echocardiography for the detection of patent foramen ovale in patients with cryptogenic cerebral ischemia: A systematic review and diagnostic test accuracy meta‐analysis

Katsanos, Aristeidis H.; Ψαλτοπούλου, Θεοδώρα; Sergentanis, Theodoros N.; Frogoudaki, Alexandra; Vrettou, Agathi‐Rosa; Ikonomidis, Ignatios; Paraskevaidis, Ioannis; Parissis, John; Bogiatzi, Chrysa; Zompola, Christina; Ellul, John; Triantafyllou, Nikolaos; Voumvourakis, Konstantinos; Kyritsis, Athanassios P.; Giannopoulos, Sotirios; Alexandrov, Anne W.; Tsivgoulis, Georgios

doi:10.1002/ana.24609

Cited by 104 publications

(98 citation statements)

References 71 publications

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“…When comparing TCD with contrast-enhanced TTE for detection of PFO, a recent meta-analysis suggested it to be more sensitive but less specific. 41 When compared with TEE, however, there remains controversy regarding which modality is most sensitive. 35, 42 The uncertainty is likely related to differences in what is used as the gold standard for the presence of a PFO.…”

Section: Cryptogenic Stroke and Pfomentioning

confidence: 99%

Patent Foramen Ovale and Stroke

Sun

Homma

2016

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp coalesce into a single orifice that becomes the foramen secundum. The septum secundum then forms via involution of the ventrocranial wall and overlaps with the foramen secundum. The septum secundum does not close fully and an oval-shaped opening remains, which becomes the foramen ovale. 17 Prior to birth, the fetus is dependent on the maternal circulation for oxygenation, as the immature fetal lungs do not yet participate in oxygen exchange. As such, the foramen ovale (as well as the ductus arteriosus), enables shunting of blood away from the pulmonary circulation. At birth, when the neonate's lungs begin to participate in oxygen exchange, there is a precipitous drop in the pulmonary vascular resistance and there is reversal of flow through both the foramen ovale and ductus arteriosus. 18 In approximately 75% of individuals, the foramen ovale closes within a few years while in the remaining others, it stays open permanently as a PFO. EpidemiologyThe prevalence of PFO in the healthy adult population ranges from 15% to 25% on echocardiography and 15-35% on autopsy studies. 1,2,19,20 Observational and autopsy studies have showed that the prevalence of detected PFOs is lower in older patients and that detected PFOs in older individuals tend to be larger. 1,19,20 Those studies, however, may be confounded by selection and detection bias because none of the longitudinal studies have demonstrated that individual PFOs change in size. The prevalence of PFOs is equal among men and women, though there may be race-ethnic differences. 1,19,21 he foramen ovale is an important fetal structure that closes after birth in most individuals and remains open as a patent foramen ovale (PFO) in approximately 25% of the healthy population. 1-3 In these individuals, bypass of the pulmonary circulation via shunting from the right-sided venous circulation to the left-sided arterial circulation is possible. Although most patients with PFOs are completely asymptomatic, reports from the late 1800 s by Cohnheim and Litten described cases of patients who were found to have the triad of deep venous thrombosis (DVT), PFO and systemic embolization. They hypothesized that the PFO enabled bypass of a venous thrombosis to the systemic arterial circulation, a process now termed paradoxical embolization. 4,5 Since those initial observations, additional studies have demonstrated a strong association between the presence of PFO and cryptogenic stroke in young patients. 6-11 In addition to its association with stroke, PFO has also been implicated in platypneaorthodeoxia, 12 decompression illness, 13 myocardial infarction, 14 obstructive sleep apnea, 15 and migraine headaches. 16 This review will focus on the relationship between PFO and stroke, discussing the embryology, epidemiology, association, mechanisms, diagnostic methods, associated anatomic factors and management strategies. EmbryologyThe right and left atria begin as a single chamber and separation b...

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Section: Cryptogenic Stroke and Pfomentioning

confidence: 99%

Patent Foramen Ovale and Stroke

Sun

Homma

2016

Circ J

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“…It can also aid in evaluating cryptogenic stroke by detecting a patent foramen ovale (PFO) or in identifying emboli in the setting of symptomatic spontaneous dissections. 5,8,20 Whereas these modalities are used primarily to determine the cause of an acute ischemic stroke, 4D CTA and MRA can be more helpful in identifying the true infarct core and potential The evaluation and management of acute ischemic stroke has primarily relied on the use of conventional CT and MRI techniques as well as lumen imaging sequences such as CT angiography (CTA) and MR angiography (MRA). Several newer or less-established imaging modalities, including vessel wall MRI, transcranial Doppler ultrasonography, and 4D CTA and MRA, are being developed to complement conventional CT and MRI techniques.…”

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confidence: 99%

Advanced imaging in acute ischemic stroke

Kilburg¹,

McNally

Havenon

et al. 2017

FOC

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The evaluation and management of acute ischemic stroke has primarily relied on the use of conventional CT and MRI techniques as well as lumen imaging sequences such as CT angiography (CTA) and MR angiography (MRA). Several newer or less-established imaging modalities, including vessel wall MRI, transcranial Doppler ultrasonography, and 4D CTA and MRA, are being developed to complement conventional CT and MRI techniques. Vessel wall MRI provides high-resolution analysis of both extracranial and intracranial vasculature to help identify previously occult lesions or characteristics of lesions that may portend a worse natural history. Transcranial Doppler ultrasonography can be used in the acute setting as a minimally invasive way of identifying large vessel occlusions or monitoring the response to stroke treatment. It can also be used to assist in the workup for cryptogenic stroke or to diagnose a patent foramen ovale. Four-dimensional CTA and MRA provide a less invasive alternative to digital subtraction angiography to determine the extent of the clot burden and the degree of collateral blood flow in large vessel occlusions. Along with technological advances, these new imaging modalities are improving the diagnosis, workup, and management of acute ischemic stroke— roles that will continue to expand in the future.

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“…4 High sensitivity has been reported for TCD (89%-97%) and some authors found TCD to be even more sensitive than TEE to detect RLC, and false-negative TCDs have been demonstrated to be due to small-size PFO. [12][13][14][15][16][17][18][19] In the present study, we evaluated the use of TCD to detect RLC and we compared the results with those obtained by TTE and TEE.…”

mentioning

confidence: 99%

Transcranial Doppler to Detect Right to Left Communication: Evaluation Versus Transesophageal Echocardiography in Real Life

et al. 2017

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We compared transcranial Doppler (TCD) with transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE) for the detection of right to left communication (RLC) in the heart. All patients explored from 2013 to 2016 in a vascular medicine unit to detect RLC by TCD were included. Right to left communication was detected by TCD monitoring for microembolic signals after intravenous injection of agitated 5% glucose and air. One hundred one patients were explored for RLC by TCD, 64 by TEE (not possible in 10, bubble injection in 51), and 93 by TTE because of unexplained stroke or arterial thrombosis (51 males, 50 females, age 51.0 ± 15.8 years) (bubble injection in 35). Fifty-three patients were positive after TCD (TEE: 4 negative, TTE: 7 negative). Of the negative patients after TCD, none was positive for TEE and 1 was positive for TTE with no evidence of patent foramen ovale. Transcranial Doppler was sensitive to detect RLC, even in patients with negative TTE or TTE. A negative TEE did not exclude RLC demonstrated by TCD. Transcranial Doppler might be proposed as first line to detect RLC.

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Transcranial Doppler versus transthoracic echocardiography for the detection of patent foramen ovale in patients with cryptogenic cerebral ischemia: A systematic review and diagnostic test accuracy meta‐analysis

Abstract: TCD is more sensitive but less specific compared to TTE for the detection of PFO in patients with cryptogenic cerebral ischemia. The overall diagnostic yield of TCD appears to outweigh that of TTE.

Cited by 104 publications

References 71 publications

Patent Foramen Ovale and Stroke

Patent Foramen Ovale and Stroke

Advanced imaging in acute ischemic stroke

Transcranial Doppler to Detect Right to Left Communication: Evaluation Versus Transesophageal Echocardiography in Real Life

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