Department of Neurology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
Brain Behav. 2024 Nov;14(11):e70144. doi: 10.1002/brb3.70144.
Cryptogenic stroke (CS), a subtype of ischemic stroke with undetermined etiology, accounts for approximately 25% of the cases. Patent foramen ovale (PFO) is an important potential cause of CS via paradoxical embolism. While transesophageal echocardiography (TEE) is the current gold standard for PFO detection, transcranial Doppler (TCD) ultrasound offers a noninvasive alternative with potential advantages in sensitivity for right-to-left shunt (RLS) detection. This study's main goal is to evaluate the diagnostic performance of TCD compared to TEE for PFO detection in CS patients.
We prospectively enrolled 110 patients aged 18-65 years with confirmed CS from 2020 to 2024. All underwent TCD screening for RLS using a standardized protocol. Subsequently, they were categorized based on a simplified version of the Spencer Logarithmic Scale, followed by confirmatory TEE. Clinical characteristics, imaging findings, TCD results, and indications for PFO closure were analyzed.
The mean age of the cohort was 45 years, with 58.2% being males. TEE identified PFO in 44.5% (49/110) of subjects. TCD accurately detected RLS in 42 of the 49 PFO cases (85.7%) confirmed by TEE. For PFO detection, TCD demonstrated a sensitivity of 85.4%, specificity of 88.5%, PPV of 85.4%, and Youden's index of 0.73. Notably, of the seven PFO cases missed by TCD, none received percutaneous closure based on clinical criteria.
TCD exhibited high diagnostic accuracy for detecting high-risk PFO in patients with CS when compared to the gold-standard TEE. As a noninvasive modality, TCD may serve as an effective screening tool to identify CS patients who could potentially benefit from confirmatory TEE and subsequent PFO closure intervention. The findings support the use of TCD as a screening tool to triage CS patients for confirmatory TEE and potential PFO closure.
隐源性卒中（CS）是一种病因不明的缺血性卒中亚型，约占病例的 25%。卵圆孔未闭（PFO）是通过反常栓塞导致 CS 的一个重要潜在原因。虽然经食管超声心动图（TEE）是目前检测 PFO 的金标准，但经颅多普勒（TCD）超声提供了一种非侵入性的替代方法，具有检测右向左分流（RLS）的潜在优势。本研究的主要目的是评估 TCD 检测 CS 患者 PFO 的诊断性能与 TEE 的比较。
我们前瞻性纳入了 2020 年至 2024 年期间确诊的 110 例年龄在 18-65 岁的 CS 患者。所有患者均接受了使用标准化方案进行的 RLS 筛查 TCD。随后，根据 Spencer 对数量表的简化版本对他们进行分类，然后进行确认性 TEE。分析了临床特征、影像学发现、TCD 结果和 PFO 闭合的适应证。
队列的平均年龄为 45 岁，其中 58.2%为男性。TEE 在 110 例患者中的 44.5%（49/110）中发现了 PFO。TCD 准确地检测到了 49 例 TEE 确认的 PFO 中的 42 例（85.7%）中的 RLS。对于 PFO 检测，TCD 的敏感性为 85.4%，特异性为 88.5%，PPV 为 85.4%，Youden 指数为 0.73。值得注意的是，TCD 漏诊的 7 例 PFO 中，无一例根据临床标准接受经皮闭合。
与金标准 TEE 相比，TCD 在检测 CS 患者高危 PFO 方面表现出了较高的诊断准确性。作为一种非侵入性的方法，TCD 可以作为一种有效的筛查工具，用于识别可能受益于确认性 TEE 和随后的 PFO 闭合干预的 CS 患者。这些发现支持使用 TCD 作为筛查工具对 CS 患者进行 TEE 确认和潜在的 PFO 闭合。
