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Tian L, Zhang M, Nie H, Zhang G, Luo X, Yuan H. Contrast-enhanced transcranial doppler versus contrast transthoracic echocardiography for right-to-left shunt diagnosis. J Clin Monit Comput 2023; 37:1145-1151. [PMID: 36808597 PMCID: PMC10520160 DOI: 10.1007/s10877-023-00979-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/28/2023] [Indexed: 02/21/2023]
Abstract
RLS can be diagnosed using US, CT angiography, and right heart catheterization. However, most reliable diagnostic modality remains undetermined. c-TCD was more sensitive than c-TTE in the diagnosis of RLS. This was true especially for the detection of provoked shunts or mild shunts. c-TCD can be used as the preferred screening method for RLS.
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Affiliation(s)
- Li Tian
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China
| | - Min Zhang
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China.
| | - Hongjun Nie
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China
| | - Guanling Zhang
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China
| | - Xiaoyan Luo
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China
| | - Huaiyun Yuan
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China
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Xiao L, Yan YH, Ding YF, Liu M, Kong LJ, Hu CH, Hui PJ. Evaluation of right-to-left shunt on contrast-enhanced transcranial Doppler in patent foramen ovale-related cryptogenic stroke: Research based on imaging. World J Clin Cases 2022; 10:143-154. [PMID: 35071514 PMCID: PMC8727250 DOI: 10.12998/wjcc.v10.i1.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/04/2021] [Accepted: 11/30/2021] [Indexed: 02/06/2023] Open
Abstract
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 (Ptrend = 0.017 and 0.009, respectively), small (Ptrend = 0.035 and 0.006, respectively) and cortical (Ptrend = 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.
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Affiliation(s)
- Lei Xiao
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Yan-Hong Yan
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Ya-Fang Ding
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Man Liu
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Li-Juan Kong
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Chun-Hong Hu
- Department of Radiology, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Pin-Jing Hui
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
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Liu Y, Wu Y, Xiong L. Surgical vs. drug therapy in patients with patent foramen ovale and cryptogenic stroke. Herz 2020; 46:250-254. [PMID: 32394019 DOI: 10.1007/s00059-020-04921-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 04/06/2020] [Accepted: 04/10/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aimed to investigate the effectiveness of risk scoring for predicting stroke recurrence after percutaneous patent foramen ovale (PFO) closure or medication therapy in patients with PFO and a history of cryptogenic stroke. METHODS This study included 559 patients with PFO and cryptogenic stroke who were treated in our hospital from January 2013 to January 2018 and were followed up for 15-72 months. After calculating the risk scores for stroke recurrence, we randomly divided the patients into two groups (ratio, 1:1): Patients in one group underwent PFO closure and those in the other received drug therapy. RESULTS Patients in the PFO closure group had a lower risk of recurrent stroke than those in the drug therapy group (1.1% vs. 4.2%). Moreover, serious bleeding was less frequent in the PFO closure group than in the drug therapy group (0% vs. 3.2%), although the incidence of atrial fibrillation or flutter did not significantly differ between the groups (p = 0.67). Interestingly, a subgroup analysis revealed no inter-treatment group difference in the rate of cryptogenic stroke recurrence among patients with risk scores of 0-1. By contrast, PFO closure yielded superior outcomes among patients with risk scores of ≥2. CONCLUSION Compared with drug therapy, PFO closure reduced the risk of recurrent stroke among patients with a risk score of ≥2 and reduced the incidence of serious bleeding without increasing the risk of new-onset atrial fibrillation or atrial flutter.
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Affiliation(s)
- Yunbing Liu
- Cardiac Electrophysiological Center, Mianyang Central Hospital, 621000, Mianyang, Sichuan, China.
| | - Yi Wu
- Cardiac Electrophysiological Center, Mianyang Central Hospital, 621000, Mianyang, Sichuan, China
| | - Lu Xiong
- Cardiac Electrophysiological Center, Mianyang Central Hospital, 621000, Mianyang, Sichuan, China
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He D, Shi Q, Xu G, Hu Z, Li X, Li Q, Guo Y, Xu S, Lin Y, Yu Z, Wang W, Luo X. Clinical and infarction patterns of PFO-related cryptogenic strokes and a prediction model. Ann Clin Transl Neurol 2018; 5:1323-1337. [PMID: 30480027 PMCID: PMC6243387 DOI: 10.1002/acn3.647] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/23/2018] [Accepted: 08/12/2018] [Indexed: 12/29/2022] Open
Abstract
Objectives The higher than expected PFO rate in CS patients has raised concerns that paradoxical embolism maybe the pathophysiologic mechanism for strokes. However, only a small proportion of pathogenic PFOs cause CS. Therefore, accurate recognition of patients with pathogenic PFOs among all CS patients could guide clinical decision making in selecting the most appropriate treatment. The aim of this study was to devise a new algorithm to stratify cryptogenic stroke (CS) patients into pathogenic patent foramen ovale (p‐PFO)‐ and non‐p‐PFO‐related patients. Methods A total of 1201 patients with acute ischemic stroke were recruited from two different medical centers, and 253 CS patients were identified. Of the 253 patients, 111 were diagnosed with PFO using contrast transcranial Doppler. Data on medical histories, neuroimaging and laboratory tests were compared in CS patients with or without PFO. Results Compared with PFO‐negative CS patients, PFO‐positive CS patients showed younger onset age, lower incidence of hypertension and dyslipidemia, characteristic infarction pattern in magnetic resonance imaging and specifically altered platelet activity and coagulation function. Based on the above information, we constructed a PFO judgment formula (Hr‐PFOJ) by means of feature weight estimation and predictive performance evaluation to predict pathogenic PFO in CS patients with a sensitivity of 76.3% and a specificity of 66.5%. Interpretations Hr‐PFOJ judgment formula is a useful screening tool for identification of patients with pathogenic PFO who may benefit from PFO‐related treatment.
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Affiliation(s)
- Dan He
- Department of Neurology National Key Clinical Department and Key Discipline of Neurology The First Affiliated Hospital Sun Yat-sen University Guangzhou Guangdong China
| | - Qiang Shi
- School of Software Engineering Huazhong University of Science & Technology Wuhan China
| | - Guangjing Xu
- Department of Neurology Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan Hubei China
| | - Zheng Hu
- Department of Obstetrics and Gynecology The First Affiliated Hospital Sun Yat-sen University Guangzhou Guangdong China
| | - Xuefei Li
- Department of Neurology Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan Hubei China
| | - Qian Li
- Department of Neurology Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan Hubei China
| | - Yinping Guo
- Department of Neurology Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan Hubei China
| | - Shabei Xu
- Department of Neurology Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan Hubei China
| | - Yongbo Lin
- Department of Neurology Wuhan Dongxihu People's Hospital Wuhan China
| | - Zhiyuan Yu
- Department of Neurology Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan Hubei China
| | - Wei Wang
- Department of Neurology Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan Hubei China
| | - Xiang Luo
- Department of Neurology Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan Hubei China
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Jiang XH, Wang SB, Tian Q, Zhong C, Zhang GL, Li YJ, Lin P, You Y, Guo R, Cui YH, Xing YQ. Right-to-left shunt and subclinical ischemic brain lesions in Chinese migraineurs: a multicentre MRI study. BMC Neurol 2018; 18:18. [PMID: 29444659 PMCID: PMC5813373 DOI: 10.1186/s12883-018-1022-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 02/06/2018] [Indexed: 11/29/2022] Open
Abstract
Background Migraine is considered as a risk factor for subclinical brain ischemic lesions, and right-to-left shunt (RLS) is more common among migraineurs. This cross-sectional study assessed the association of RLS with the increased prevalence of subclinical ischemic brain lesions in migraineurs. Methods We enrolled 334 migraineurs from a multicentre study from June 2015 to August 2016. Participants were all evaluated using contrast-enhanced transcranial Doppler, magnetic resonance imaging (MRI), and completed a questionnaire covering demographics, the main risk factors of vascular disease, and migraine status. RLS was classified into four grades (Grade 0 = Negative; Grade I = 1 ≤ microbubbles (MBs) ≤ 10; Grade II = MBs > 10 and no curtain; Grade III = curtain). Silent brain ischemic infarctions (SBI) and white matter hyperintensities (WMHs) were evaluated on MRI. Results We found no significant differences between migraineurs with RLS and migraineurs without RLS in subclinical ischemic brain lesions.SBI and WMHs did not increase with the size of the RLS(p for trend for SBI = 0.066, p for trend for WMHs = 0.543). Furthermore, curtain RLS in migraineurs was a risk factor for the presence of SBI (p = 0.032, OR = 3.47; 95%CI: 1.12−10.76). There was no association between RLS and the presence of WMHs. Conclusion Overall, RLS is not associated with increased SBI or WMHs in migraineurs. However, when RLS is present as a curtain pattern, it is likely to be a risk factor for SBIs in migraineurs. Trial registration No. NCT02425696; registered on April 21, 2015. Electronic supplementary material The online version of this article (10.1186/s12883-018-1022-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiao-Han Jiang
- Neuroscience Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Si-Bo Wang
- Neuroscience Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Qian Tian
- Department of Neurology, People's Hospital of Linyi City, Linyi, China
| | - Chi Zhong
- Department of Neurology, Weifang People's Hospital, Weifang, China
| | - Guan-Ling Zhang
- Department of Ultrasound, The Centre Hospital of Changsha City, Changsha, China
| | - Ya-Jie Li
- Diagnostic Ultrasound Centre, The Centre Hospital of Jilin City, Jilin, China
| | - Pan Lin
- Department of Neurology, The Second Hospital of Longyan City, Longyan, China
| | - Yong You
- Department of Neurology, The First Hospital of University of South China, Hengyang, China
| | - Rong Guo
- Department of Neurology Function, The People's Hospital of Liaoning Province, Shenyang, China
| | - Ying-Hua Cui
- Centre of Head and Neck Vascular Ultrasound, Department of Neurology, The Hospital of Yanbian University, Yanji, China
| | - Ying-Qi Xing
- Neuroscience Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, China.
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Wang SB, Wang XC, Ma Y, Liu KD, Xing YQ. Right-to-left shunt detection using contrast-enhanced transcranial Doppler: A comparison of provocation maneuvers between coughing and a modified Valsalva maneuver. PLoS One 2017; 12:e0175049. [PMID: 28384297 PMCID: PMC5383058 DOI: 10.1371/journal.pone.0175049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/20/2017] [Indexed: 01/03/2023] Open
Abstract
Contrast-enhanced transcranial Doppler (c-TCD) has been used to detect right-to-left shunts (RLS) because it is highly sensitive and cost-effective. The use of provocation maneuvers, such as physiologic maneuvers (e.g., coughing) and the Valsalva maneuver (VM) to transiently increase right atrial pressure and induce RLS increases the sensitivity of RLS detection. In this study, we sought to determine whether coughing is as effective as the VM in aiding the detection of RLS. We evaluated 162 subjects for RLS, using c-TCD under three different conditions: (i) resting state, (ii) coughing, and (iii) modified VM (m-VM), which involved blowing into a tube connected to a sphygmomanometer at 40 mmHg for 10 s. The positive rate of RLS detection with the m-VM was significantly higher than that with coughing. In addition, a difference between the two maneuvers was observed in terms of the degree of RLS seen. The m-VM should be widely used to detect RLS, because it is reliable, standardized, and cost-effective.
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Affiliation(s)
- Si-Bo Wang
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xiao-Cong Wang
- Department of Echocardiography, Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Yan Ma
- Department of Echocardiography, Cardiovascular Center, The First Hospital of Jilin University, Changchun, China
| | - Kang-Ding Liu
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
- * E-mail: (YQX); (KDL)
| | - Ying-Qi Xing
- Neuroscience Center, Department of Neurology, The First Hospital of Jilin University, Changchun, China
- * E-mail: (YQX); (KDL)
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Affiliation(s)
- A H V Schapira
- Department of Clinical Neurosciences, UCL Institute of Neurology, London, UK.
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Right-to-Left Shunt Does Not Increase the Incidence of Silent Lacunar Infarcts in Patients with Migraine. BIOMED RESEARCH INTERNATIONAL 2015; 2015:749745. [PMID: 26266262 PMCID: PMC4523651 DOI: 10.1155/2015/749745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 06/23/2015] [Indexed: 11/29/2022]
Abstract
Right-to-left shunt (RLS) is associated with cryptogenic stroke and migraine. Herein we investigated the relationship between RLS and silent lacunar infarcts in patients with migraine. A total of 263 patients with migraine who met eligibility criteria were enrolled from January 2010 to December 2011, among which 127 subjects fell into RLS group. Baseline demographics were comparable between RLS and non-RLS groups (P > 0.05). The incidence of silent lacunar infarcts in RLS group was not significantly different from that of the non-RLS group (25.2% versus 21.3%, P > 0.05). Furthermore, we found that the incidence of silent lacunar infarcts in permanent and latent RLS subgroups was comparable with non-shunt RLS subgroup (28.6% versus 24% versus 21.3%, P > 0.05). Similarly, the incidence of silent lacunar infarcts in the non-RLS group, mild-shunt group, and large-shunt group was also comparable (21.3% versus 23.8% versus 29.3%, P > 0.05). In addition, RLS did not increase the incidence of silent lacunar infarcts in migraine patients with elder age (<50 years age group: 15.8% versus 17.9%; ≥50 years age group: 53.1% versus 37.5%, both P > 0.05). In conclusion, RLS does not increase the incidence of silent lacunar infarcts in patients with migraine. Further prospective studies are warranted to validate this finding.
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