Patent foramen ovale: comparison among diagnostic strategies in cryptogenic stroke and migraine.
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.
Zito
Concetta
C
Dipartimento di Medicina e Farmacologia, Università di Messina, Messina, Italy. tittizito@libero.it
Dattilo
Giuseppe
G
Oreto
Giuseppe
G
Di Bella
Gianluca
G
Lamari
Annalisa
A
Iudicello
Raffaella
R
Trio
Olimpia
O
Caracciolo
Giuseppe
G
Coglitore
Sebastiano
S
Arrigo
Francesco
F
Carerj
Scipione
S
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