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Right-to-Left Shunt Evaluation in Cardiac Patent Foramen Ovale Using Bubble Contrast Transcranial Color-Coded
Myeong-Hoon Ji1,2, Youl-Hun Seoung1
1Department of Radiological Science, College of Health and Medical Sciences, Cheongju University, Cheongju 28503, Republic of Korea.
Insights
Contrast transcranial color-coded Doppler (C-TCCD) offers a superior method for detecting right-to-left shunts (RLS) in patent foramen ovale (PFO). This advanced technique aids in diagnosing the cause of cryptogenic stroke when traditional methods fall short.
Area of Science:
- Cardiology
- Neurology
- Medical Imaging
Background:
- Patent foramen ovale (PFO) diagnosis traditionally uses transcranial Doppler (TCD), a method limited by its inability to visualize vessels directly.
- TCD's reliance on qualitative assessment introduces potential errors, impacting examination reproducibility and consistency.
Observation:
- A case study involving a patient with ischemic stroke of unknown origin was presented.
- Contrast transcranial color-coded Doppler (C-TCCD) with bubble contrast was utilized for right-to-left shunt (RLS) screening.
- C-TCCD successfully identified RLS, leading to further investigation with transesophageal echocardiography (TEE).
Findings:
- TEE confirmed an 8 mm PFO, a 21 mm tunnel length, a hypermobile interatrial septum, and persistent RLS.
- The patient's high-risk PFO score was calculated at 4 points, indicating a very high-risk PFO.
- C-TCCD proved effective in screening for RLS associated with PFO.
Implications:
- C-TCCD serves as a valuable alternative for assessing RLS in PFO, particularly in cryptogenic stroke cases.
- This method enhances diagnostic accuracy for identifying the underlying causes of ischemic stroke.
- The findings highlight the importance of advanced imaging techniques in complex cardiac and neurological diagnoses.
Abstract:
Traditional diagnosis of patent foramen ovale (PFO) in the heart has involved the use of transcranial Doppler (TCD). However, TCD is essentially a blind test that cannot directly visualize the location of blood vessels. Since TCD relies on qualitative assessments by examiners, there is room for errors, such as misalignment of the ultrasound's angle of incidence with the actual blood vessels. This limitation affects the reproducibility and consistency of the examination. In this study, we presented an alternative approach for assessing right-to-left shunt (RLS) associated with PFO using contrast transcranial color-coded Doppler (C-TCCD) with bubble contrast. The patient under consideration had been diagnosed with an ischemic stroke through imaging, but the subsequent cardiac work-up failed to determine the cause. Employing C-TCCD for RLS screening revealed a confirmed RLS of Spencer's three grades. Subsequently, transesophageal echocardiography (TEE) was conducted to evaluate PFO risk factors, confirming an 8 mm PFO size, a 21 mm tunnel length, a hypermobile interatrial septum, and persistent RLS. The calculated high-risk PFO score was 4 points, categorizing it as a very high risk PFO. This case underscores the importance of C-TCCD screening in detecting RLS associated with PFO, especially in cryptogenic stroke patients, when identifying the underlying cause of ischemic stroke becomes challenging.
