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The RoPE Score and Right-to-Left Shunt Severity by Transcranial Doppler in the CODICIA Study
Benjamin S Wessler1, David M Kent, David E Thaler
1Division of Cardiology, Tufts Medical Center, Boston, Mass., USA.
Insights
Contrast transcranial Doppler (c-TCD) effectively quantifies right-to-left shunt (RLSh) severity in cryptogenic stroke (CS) patients with patent foramen ovale (PFO). This grading correlates with the Risk of Paradoxical Embolism (RoPE) score and c-TCD shows higher sensitivity than TEE for RLSh detection.
Area of Science:
- Neurology
- Cardiology
- Medical Imaging
Background:
- Cryptogenic stroke (CS) patients with patent foramen ovale (PFO) present diagnostic challenges regarding the significance of right-to-left shunt (RLSh).
- The correlation between RLSh magnitude measured by contrast transcranial Doppler (c-TCD) and the likelihood of PFO-related CS (Risk of Paradoxical Embolism [RoPE] score) remains unclear.
- The comparative sensitivity of c-TCD versus transesophageal echocardiography (TEE) for RLSh detection in CS patients is not well-established.
Purpose of the Study:
- To determine the significance of RLSh grade assessed by c-TCD in patients diagnosed with PFO and CS.
- To investigate the association between c-TCD shunt grade and the RoPE score in CS patients.
- To compare the sensitivity of c-TCD and TEE in identifying and grading RLSh.
Main Methods:
- Evaluation of patients with CS and quantified RLSh by c-TCD within the Multicenter Study into RLSh in Cryptogenic Stroke (CODICIA).
- Analysis of the association between c-TCD shunt grade and the RoPE score.
- Comparison of RLSh detection and grading between c-TCD and TEE in patients who underwent both procedures.
Main Results:
- The RoPE score demonstrated predictive capability for the presence versus absence of RLSh documented by c-TCD (c-statistic = 0.66).
- A positive correlation was observed between shunt severity quantified by c-TCD and increasing RoPE scores (rank correlation (r) = 0.15, p = 0.01).
- In 293 patients with both c-TCD and TEE, c-TCD exhibited higher sensitivity (98.7%) for RLSh detection. Notably, 29% of patients with no PFO identified on TEE showed significant RLSh on c-TCD.
Conclusions:
- RLSh severity assessed by c-TCD is positively correlated with the RoPE score in CS patients, suggesting pathogenic PFOs.
- c-TCD demonstrates superior sensitivity in detecting RLSh compared to TEE.
- These findings highlight the significant role of c-TCD in evaluating PFO in the context of cryptogenic stroke.
Background:
For patients with cryptogenic stroke (CS) and patent foramen ovale (PFO), it is unknown whether the magnitude of right-to-left shunt (RLSh) measured by contrast transcranial Doppler (c-TCD) is correlated with the likelihood an identified PFO is related to CS as determined by the Risk of Paradoxical Embolism (RoPE) score. Additionally, for patients with CS, it is unknown whether PFO assessment by c-TCD is more sensitive for identifying RLSh compared with transesophageal echocardiography (TEE). Our aim was to determine the significance of RLSh grade by c-TCD in patients with PFO and CS.
Methods:
We evaluated patients with CS who had RLSh quantified by c-TCD in the Multicenter Study into RLSh in Cryptogenic Stroke (CODICIA) to determine whether there is an association between c-TCD shunt grade and the RoPE Score. For patients who underwent c-TCD and TEE, we determined whether there is agreement in identifying and grading RLSh between these two modalities.
Results:
The RoPE score predicted the presence versus the absence of RLSh documented by c-TCD (c-statistic = 0.66). For patients with documented RLSh by c-TCD, shunt severity was correlated with increasing RoPE score (rank correlation (r) = 0.15, p = 0.01). Among 293 patients who had both c-TCD and TEE performed, c-TCD was more sensitive (98.7%) for detecting RLSh. Of the 97 patients with no PFO identified on TEE, 28 (29%) had a large amount of RLSh seen on c-TCD.
Conclusions:
For patients with CS, severity of RLSh by c-TCD is positively correlated with the RoPE score, indicating that this technique for shunt grading identifies patients more likely to have pathogenic rather than incidental PFOs. c-TCD is also more sensitive in detecting RLSh than TEE. These findings suggest an important role for c-TCD in the evaluation of PFO in the setting of CS.
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