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Transcranial Doppler for stratification of high-risk morphology of patent foramen ovale in patients with cryptogenic stroke

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Abstract

Microbubble testing using transcranial Doppler (TCD) is an important screening tool for diagnosing paradoxical cerebral embolism with high-risk PFO. However, little is known about the association between the microbubble test by TCD and the features of high-risk PFO evaluated by transesophageal echocardiography (TEE). We studied 101 consecutive patients at Showa University, from April 2019 to October 2020, who underwent both TCD and TEE with a sufficient Valsalva maneuver and who were strongly suspected by neurologists as cryptogenic stroke. According to the appearance of microbubbles as high-intensity transient signals (HITS), the TCD grade was stratified into three categories based on the criteria (A: none, no HITS, B: small; 1–10 HITS, and C: large; > 10 HITS, or an uncountable number of HITS). Among patients with RLS through the PFO in TEE, high-risk morphological features of PFO for cerebral embolism were evaluated as follows: (1) tunnel height, (2) tunnel length, (3) total excursion distance of the atrial septum into the right and left atrium, (4) existence of Eustachian valve or Chiari network, (5) angle of PFO from the inferior vena cava, and (6) large shunt (20 or more microbubbles). Of 101 patients (TCD grade; Group A = 49, Group B = 26, Group C = 26), RLS through PFO was detected in 37 patients (grade A = 8, grade B = 6, grade C = 23) by TEE. Among PFO-positive patients, tunnel height, length, total excursion distance into the right and left atria, angle of PFO from the inferior vena cava, and frequency of large shunt in TEE were significantly larger in grade C than in grade A and B (p < 0.05). Additionally, grade C patients had significantly more forms of high-risk PFOs than those in grades A and B when the six features of high-risk PFO were compared. A multivariate logistic regression demonstrated that the tunnel length of PFO and the presence of large shunt in TEE were independently associated with large HITS in TCD (odds ratio: 1.18 and 49.5, 95% confidence interval 1.043–1.337 and 10.05–244.3, p = 0.0086 and p < 0.0001, respectively). In conclusion, the existence of a large HITS detected by TCD may have a screening advantage in predicting the high-risk morphologies of PFO that can cause paradoxical cerebral embolism.

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Abbreviations

CS:

Cryptogenic stroke

ESUS:

Embolic stroke of undetermined source

TCD:

Transcranial Doppler

TEE:

Transesophageal echocardiography

HITS:

High-intensity transient signals

PFO:

Patent foramen ovale

RLS:

Right-to-left shunt

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Acknowledgements

The authors are grateful for the support of the entire staff of the Ultrasound Examination Center, Showa University Hospital and we would like to thank Editage (www.editage.com) for English language editing.

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Authors and Affiliations

  1. Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan

    Saori Chino, Yasuhide Mochizuki, Saaya Ichikawa, Haruka Miyazaki, Rumi Hachiya, Eiji Toyosaki, Masashi Ota, Hiroto Fukuoka & Toshiro Shinke

  2. Division of Neurology, Department of Internal Medicine, Showa University, Tokyo, Japan

    Keita Mizuma & Kenjiro Ono

  3. Department of Pathology, Showa University, Tokyo, Japan

    Toshiko Yamochi

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  1. Saori Chino
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Correspondence to Yasuhide Mochizuki.

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Chino, S., Mochizuki, Y., Mizuma, K. et al. Transcranial Doppler for stratification of high-risk morphology of patent foramen ovale in patients with cryptogenic stroke. Heart Vessels 37, 2119–2127 (2022). https://doi.org/10.1007/s00380-022-02117-9

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