title: Diagnosis of right-to-left shunt with transcranial Doppler and vertebrobasilar recording.
abstract: OBJECTIVE
  Right-to-left shunt (RLS) due to patent foramen ovale is a well-established risk factor for cryptogenic stroke and is highly prevalent in cases of migraine, cluster headache, and obstructive apnea. It can be diagnosed by gaseous-contrast transcranial Doppler, yet in a small percentage of cases it cannot be done owing to an insufficient temporal window. The aim of the study was to compare transtemporal with transoccipital approaches for gaseous-contrast transcranial Doppler for RLS diagnosis.
  
  
  METHODS
  We evaluated 183 subjects with a standard protocol for RLS diagnosis by simultaneously monitoring the right middle cerebral and vertebrobasilar circulations.
  
  
  RESULTS
  Vertebrobasilar recording reached high specificity (100%) and good sensitivity (83.72%) for the diagnosis of RLS after the Valsalva maneuver. For only medium and large shunts, both sensitivity and specificity reached 100%. Time to bubble appearance after injection was higher in the vertebrobasilar circulation (4.36+/-1.7 vs 6.77+/-2.5 seconds; P<0.001). There was a positive correlation between the number of bubbles in the right middle cerebral and vertebrobasilar circulation (kappa=0.97).
  
  
  CONCLUSIONS
  Transcranial Doppler with vertebrobasilar monitoring is highly sensitive and specific in detecting RLS, particularly when medium or large. It can be proposed for subjects with an insufficient temporal bone window.
authors.affiliation: Department of Neurosciences, Ophthalmology, and Genetics, University of Genova, Genova, Italy. mdelsette@neurologia.unige.it
authors.forename: Massimo
authors.initials: M
authors.lastname: Del Sette
authors.forename: Lavinia
authors.initials: L
authors.lastname: Dinia
authors.forename: Domenica
authors.initials: D
authors.lastname: Rizzi
authors.forename: Annalisa
authors.initials: A
authors.lastname: Sugo
authors.forename: Beatrice
authors.initials: B
authors.lastname: Albano
authors.forename: Carlo
authors.initials: C
authors.lastname: Gandolfo
mesh_terms: D000328:Adult; D001488:Basilar Artery / Q000503:physiopathology; D002560:Cerebrovascular Circulation; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000503:physiopathology; D009777:Occipital Bone / Q000033:anatomy & histology / Q000000981:diagnostic imaging; D011237:Predictive Value of Tests; D013701:Temporal Bone / Q000033:anatomy & histology / Q000000981:diagnostic imaging; D017585:Ultrasonography, Doppler, Transcranial / Q000379:methods*; D014711:Vertebral Artery / Q000503:physiopathology; D014715:Vertebrobasilar Insufficiency / Q000000981:diagnostic imaging* / Q000209:etiology / Q000503:physiopathology