title: Patent foramen ovale: comparison among diagnostic strategies in cryptogenic stroke and migraine.
abstract: OBJECTIVE
  The aim of this study was to compare transthoracic echocardiography (TTE) and transcranial Doppler ultrasonography (TCD) with transesophageal echocardiography (TEE) in order to define the best clinical approach to patent foramen ovale (PFO) detection.
  
  
  METHODS
  In total, 72 consecutive patients (33 men) with a mean age of 49 +/- 13 years were prospectively enrolled. The TEE indication was cryptogenic stroke (36 patients) or migraine (36 patients, 22 with aura). All patients underwent standard TTE, TCD, and TEE examination. For any study, a contrast test was carried on using an agitated saline solution mixed with urea-linked gelatine (Haemaccel), injected as a rapid bolus via a right antecubital vein. A prolonged Valsalva maneuver was performed to improve test sensitivity.
  
  
  RESULTS
  TEE identified a PFO in 65% of the whole population: 56.5% in the migraine cohort and 43.5% in the cryptogenic stroke cohort. TTE was able to detect a PFO in 55% of patients positive at TEE (54% negative predictive value, 100% positive predictive value, 55% sensitivity, and 100% specificity). TCD was able to identify a PFO in 97% of patients positive at TEE (89% negative predictive value, 98% positive predictive value, 94% sensitivity, and 96% specificity).
  
  
  CONCLUSIONS
  In patients with cryptogenic stroke and migraine, there is a fair concordance (k = 0.89) between TCD and TEE in PFO recognition. Accordingly, TCD should be recommended as a simple, noninvasive, and reliable technique, whereas TEE indication should be restricted to selected patients. TTE is a very specific technique, whose major advantage is the ability to detect a large right-to-left shunt, particularly if associated with an atrial septal aneurysm.
authors.affiliation: Dipartimento di Medicina e Farmacologia, Università di Messina, Messina, Italy. tittizito@libero.it
authors.forename: Concetta
authors.initials: C
authors.lastname: Zito
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Dattilo
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Oreto
authors.forename: Gianluca
authors.initials: G
authors.lastname: Di Bella
authors.forename: Annalisa
authors.initials: A
authors.lastname: Lamari
authors.forename: Raffaella
authors.initials: R
authors.lastname: Iudicello
authors.forename: Olimpia
authors.initials: O
authors.lastname: Trio
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Caracciolo
authors.forename: Sebastiano
authors.initials: S
authors.lastname: Coglitore
authors.forename: Francesco
authors.initials: F
authors.lastname: Arrigo
authors.forename: Scipione
authors.initials: S
authors.lastname: Carerj
mesh_terms: D004452:Echocardiography; D005260:Female; D054092:Foramen Ovale, Patent / Q000150:complications* / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008881:Migraine Disorders / Q000000981:diagnostic imaging* / Q000209:etiology*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D020521:Stroke / Q000000981:diagnostic imaging* / Q000209:etiology*; D017585:Ultrasonography, Doppler, Transcranial