Stroke, Vol 24, 1020-1024, Copyright © 1993 by American Heart Association
M Di Tullio, RL Sacco, N Venketasubramanian, D Sherman, JP Mohr and S Homma
BACKGROUND AND PURPOSE: The prevalence of a patent foramen ovale has been
shown to be increased in patients with ischemic stroke. Transesophageal
echocardiography, transthoracic echocardiography, and transcranial Doppler
examination with contrast injection can all be used to search for a patent
foramen ovale. We compared the accuracy of these techniques for identifying
a patent foramen ovale in 49 patients with acute ischemic stroke or
transient ischemic attack. METHODS: Transcranial Doppler examination of the
right middle cerebral artery was performed during simultaneous
transthoracic echocardiography with aerated saline injection, and again
during transesophageal echocardiography; the latter was adopted as the
"gold standard" for assessing the sensitivity of the other two tests.
RESULTS: Contrast transesophageal echocardiography detected a patent
foramen ovale in 19 of 49 patients (39%), during normal respiration in 15
of them and during Valsalva maneuver in 4. Transcranial Doppler correctly
identified 13 patients with a patent foramen ovale and all 30 patients
without it. Therefore, the sensitivity of transcranial Doppler was 68%
(13/19), and its specificity 100% (30/30). The 6 patients misclassified by
transcranial Doppler (false negatives) had a very small right-to- left
shunt detected by transesophageal echocardiography. Contrast transthoracic
echocardiography was found to be the least sensitive test, detecting a
patent foramen ovale in only 9 of 19 patients (47%). The specificity of
transthoracic echocardiography was 100% (30/30 patients). The low
sensitivity of transthoracic echocardiography was principally due to the
suboptimal image quality obtained in false- negative patients. Both
transcranial Doppler and transthoracic echocardiography were more sensitive
in patients with cryptogenic stroke than in patients with stroke of
determined origin. This may indicate the presence of larger, more easily
detectable shunts in patients with cryptogenic stroke. CONCLUSIONS:
Transesophageal echocardiography is more sensitive than transcranial
Doppler examination in detecting a patent foramen ovale, but only in cases
of minimal right-to-left shunts, the clinical relevance of which remains to
be established. The sensitivity of transthoracic echocardiography is
heavily hampered by the frequency of inadequate heart visualization.
ARTICLES
Comparison of diagnostic techniques for the detection of a patent foramen ovale in stroke patients
Department of Medicine, Columbia University, New York, NY.
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