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(Stroke. 2008;39:e125.)
© 2008 American Heart Association, Inc.

Letters to the Editor

Response to Letter by Topcuoglu

Massimo Del Sette, MD; Lavinia Dinia, MD Carlo Gandolfo, MD

Department of Neurosciences, Ophtalmology and Genetics, University of Genova, Genova, Italy

Response:

We read with great interest Dr Topcuoglu’s remarks on our study about the use of vertebro-basilar (VB) approach in diagnosing right-to-left shunt by transcranial Doppler in patients with insufficient temporal bone window.¹ Dr Topcuoglu, based on previous scientific contributions,^2,3 claims that submandibular extracranial ICA (ecICA) monitoring is "superior over the suboccipital monitoring of the basilar or vertebral arteries." He had previously reported a comparison between MCA and ecICA recording for RLS diagnosis in 34 patients, with a novel nonvalidated^4–7 classification of RLS in 6 classes, reporting 77% more microbubbles detection on ecICA compared to MCA monitoring.² His conclusion is not acceptable, in our opinion, because there is no study comparing ecICA and VB monitoring; thus, we cannot say whether one test is superior to the other. In particular, neurosonologic tests, either on ICA, MCA or VB, are done for the screening of subjects with possible patent foramen ovale, which is the known risk factor for stroke, and neurologists are interested on what could reach cerebral circulation and not only extracranial carotid arteries; thus, the cases reported by Dr Topcuoglu (2 of 24) with the test positive on ecICA but negative on MCA should be considered "false-positive," totally useless for stroke prevention. Moreover, if the observation of possible probe motion during Valsalva manouvre is very important, this seems to be strongly true for ecICA monitoring, because a well-done manouvre (as can be verified only with intracranial changes in velocity) usually determines difficulties in maintaining ICA signal, due to larynx movements and jugular vein enlargement. Finally, there is no reason for Dr Topcuoglu’s concern about the complexity of VB method because the suboccipital approach doesn’t need any fixation of the probe, and the patient is not in prone position, but, as explained in the Method section, is lying in supine position with the head rotated toward one side.¹

In conclusion, based on the final goal of diagnosing relevant RLS for stroke prevention, we think that the demonstration of medium-large shunts is the one which is clinically important, and VB monitoring can be an important tool for clinicians. More data on larger samples are needed to standardize the ecICA method for RLS and patent foramen ovale diagnosis.

Acknowledgments

Disclosures

None.

References

1. Del Sette M, Dinia L, Rizzi D, Sugo A, Albano B, Gandolfo C. Diagnosis of right-to-left shunt with transcranial Doppler and vertebrobasilar recording. Stroke. 2007; 38: 2254–2256.[Abstract/Free Full Text]

2. Topcuoglu MA, Palacios IF, Buonanno FS. Contrast M-mode power Doppler ultrasound in the detection of right-to-left shunts: utility of submandibular internal carotid artery recording. J Neuroimaging. 2003; 13: 315–323.[CrossRef][Medline] [Order article via Infotrieve]

3. Draganski B, Blersch W, Holmer S, Koch H, May A, Bogdahn U, Hölscher T, Schlachetzki F. Detection of cardiac right-to-left shunts by contrast-enhanced harmonic carotid duplex sonography. J Ultrasound Med. 2005; 24: 1071–1076.[Abstract/Free Full Text]

4. Anzola GP, Renaldini E, Magoni M, Costa A, Cobelli M, Guidani M. Validation of transcranial Doppler sonography in the assessment of Patent Foramen Ovale. Cerebrovasc Dis. 1995; 5: 194–198.[CrossRef]

5. Zanette EM, Mancini G, De Castro S, Solaro M, Cartoni D, Chiarotti F. Patent foramen ovale and transcranial Doppler: comparison of different procedures. Stroke. 1996; 27: 2251–2255.[Abstract/Free Full Text]

6. Droste DW, Reisener M, Kemeny V, Dittrich R, Shulte-Altedorneburg G, Stypman J, Widimsky P, Wichter T, Ringelstein EB. Contrast transcranial Doppler ultrasound in the detection of right-to-left shunt: reproducibility, comparison of two agents, and distribution of microemboli. Stroke. 1999; 30: 1014–1018.[Abstract/Free Full Text]

7. Jauss M, Zanette E. Detection of right-to-left shunt with ultrasound contrast agent and transcranial Doppler sonography. Cerebrovasc Dis. 2000; 10: 490–496.[CrossRef][Medline] [Order article via Infotrieve]

This Article Extract Full Text (PDF) All Versions of this Article: 39/8/e125    most recent STROKEAHA.107.500074v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Del Sette, M. Articles by Gandolfo, C. Search for Related Content PubMed Articles by Del Sette, M. Articles by Gandolfo, C.