title: Optimizing the technique of contrast transcranial Doppler ultrasound in the detection of right-to-left shunts.
abstract: OBJECTIVE
  A cardiac right-to-left shunt (RLS) can be identified by transesophageal echocardiography and transcranial Doppler ultrasound (TCD) with contrast agents and a Valsalva maneuver (VM) as a provocation procedure. This article applies the modalities of these tests detailed in previous studies to a large patient cohort and compares 2 contrast agents (saline and Echovist-300).
  
  
  METHODS
  Eighty-one patients were investigated by both transesophageal echocardiography and bilateral TCD of the middle cerebral arteries. The following protocol with injections of 10 mL agitated saline was applied in a randomized way: (1) no VM, (2) VM for 5 seconds starting 5 seconds after the beginning of contrast injection, and (3) repetition of the test with VM if the first test with VM was negative. The VM was performed for 5 seconds starting exactly 5 seconds after the beginning of saline injection. Thereafter, the same protocol was repeated with 10 mL Echovist-300 instead of saline.
  
  
  RESULTS
  Thirty-one patients had a cardiac RLS. The Echovist-300 investigation disclosed all these 31 shunts, but saline disclosed only 29 of them. Twenty-two had an RLS only in at least 1 of the above TCD tests, some of them even with a considerable shunt volume.
  
  
  CONCLUSIONS
  Contrast TCD performed with Echovist-300 but not with saline yields a 100% sensitivity to identify transesophageal echocardiography-proven cardiac RLSs. The TCD test should be repeated if negative the first time. This article gives detailed information for the optimization of the contrast TCD technique. Extracardiac shunts detected only during contrast TCD can have a considerable shunt volume and may allow for paradoxical embolism.
authors.affiliation: Department of Neurology, University of Münster, Münster, Germany. droste2@uni-muenster.de
authors.forename: Dirk W
authors.initials: DW
authors.lastname: Droste
authors.forename: Stefan
authors.initials: S
authors.lastname: Lakemeier
authors.forename: Thomas
authors.initials: T
authors.lastname: Wichter
authors.forename: Jörg
authors.initials: J
authors.lastname: Stypmann
authors.forename: Ralf
authors.initials: R
authors.lastname: Dittrich
authors.forename: Martin
authors.initials: M
authors.lastname: Ritter
authors.forename: Martin
authors.initials: M
authors.lastname: Moeller
authors.forename: Michael
authors.initials: M
authors.lastname: Freund
authors.forename: E Bernd
authors.initials: EB
authors.lastname: Ringelstein
mesh_terms: D000328:Adult; D000368:Aged; D002339:Carotid Arteries / Q000000981:diagnostic imaging; D002536:Cerebral Arteries / Q000000981:diagnostic imaging; D015331:Cohort Studies; D003287:Contrast Media; D018618:Echocardiography, Doppler, Color; D017548:Echocardiography, Transesophageal; D019320:Embolism, Paradoxical / Q000175:diagnosis / Q000209:etiology; D005260:Female; D006343:Heart Septal Defects / Q000150:complications / Q000000981:diagnostic imaging*; D006344:Heart Septal Defects, Atrial / Q000150:complications / Q000000981:diagnostic imaging; D006801:Humans; D020766:Intracranial Embolism / Q000175:diagnosis / Q000209:etiology; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging; D009915:Orbit / Q000098:blood supply / Q000000981:diagnostic imaging; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D012965:Sodium Chloride / Q000008:administration & dosage; D017585:Ultrasonography, Doppler, Transcranial / Q000379:methods*; D014636:Valsalva Maneuver
chemical_list: D003287:Contrast Media; D012965:Sodium Chloride