From the Section of Neurology and Stroke Research Unit (J.S., T.S., A.M.,
A.D.) and the Service of Cardiology (J.B., M.J.P.-A.), Hospital Universitari
Doctor Josep Trueta, Girona, Spain.
Correspondence and reprint requests to J. Serena, MD, Section of Neurology, Hospital Universitari Doctor Josep Trueta, Av de França s/n, 17007 Girona, Spain. E-mail jserenal{at}meditex.es
Background and Purpose—Although
right-to-left shunt (RLSh) has been reported to be significantly more
frequent in young stroke patients with cryptogenic stroke, its
relevance in a nonselected population of acute ischemic stroke
is not well known. The aim of this study was to determine the
importance of the RLSh magnitude as a risk factor for stroke in
nonselected patients.
Methods—Two hundred eight patients hospitalized consecutively
with transient ischemic attack or acute cerebral infarction and
100 healthy control subjects were studied. Transcranial
Doppler ultrasonography (TCD) was performed in both middle cerebral
arteries (MCAs) after intravenous application of agitated
saline solution. The magnitude of RLSh was quantified by counting the
number of signals in 1 MCA during a Valsalva maneuver. RLSh was
classified as "no shunt," "small" (<10 signals), and
"large" (>10 signals), with the latter including the "shower"
(>25 signals) and "curtain" (uncountable signals) patterns.
Extensive investigations, including contrast
transesophageal echocardiography,
were carried out on patients diagnosed as suffering from stroke of an
uncertain etiology. The importance of RLSh for stroke was assessed by
logistic regression analysis.
Results—Contrast TCD detected a large RLSh in 40
(19.7%) patients and in 21 (21%) control subjects, all with cardiac
RLSh characteristics. A large RLSh was present in 4.7% of
atherothrombotic strokes, 10.5% of cardioembolic strokes, 15.4% of
lacunar strokes, and 45.3% of cryptogenic strokes
(P<0.001). Although the overall frequency of RLSh was
not significantly different between patients and control subjects, the
detection of curtain or shower patterns by contrast TCD was associated
with a higher risk of stroke (odds ratio , 3.5; 95% confidence
interval, 1.29 to 9.87), particularly with cryptogenic stroke (odds
ratio, 12.4; 95% confidence interval, 4.08 to 38.09) after adjustment
for concomitant vascular risk factors.
Conclusions—It is essential to quantify RLSh by contrast TCD
during the Valsalva maneuver given that only those with shower and
curtain patterns are associated with a higher risk of ischemic
stroke in a nonselected population.
© 1998 American Heart Association, Inc.
Original Contributions
The Need to Quantify Right-to-Left Shunt in Acute Ischemic Stroke
A Case-Control Study
Key Words: echocardiography, transesophageal • foramen ovale, patent • stroke, acute • ultrasonography, Doppler, transcranial
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