Patent foramen ovale and transcranial Doppler - Comparison of different procedures

Background and Purpose The capability of transcranial Doppler sonography (TCD) to detect a patent foramen ovale (PFO) has been established. However, which provocative maneuver and what timing of contrast injection are most effective to induce a right-to-left shunt has not yet been determined. Methods We selected 38 cerebrovascular patients (21 men, 17 women) with positive contrast study for PFO on transesophageal echocardiography. Patients underwent a TCD with bilateral monitoring of the middle cerebral arteries (MCAs) and injection of a contrast solution. The injection was repeated (1) during normal breathing (basal conditions); (2) before Valsalva maneuver (VM); (3) during VM; (4) immediately after VM; and (5) during cough. The latency time and the total number of microbubbles for each side were recorded. Results TCD found positive results for PFO in 30 patients. Twenty were positive even during basal conditions. The number of positive cases varied according to the timing of the VM in relation to the contrast injection: 28, 25, and 27 cases were positive when the injection was performed before, during, and after VM, respectively, while 26 were positive during cough. There were significant differences in the number df microbubbles in the MCAs between the procedures (P<.001, ANOVA): the highest number was detected in the injection before VM and the lowest number during basal conditions (P<.001, Wilcoxon's test with Bonferroni's correction). The latency time was significantly shorter when the injection followed VM. Conclusions The injection performed before VM appeared to be the most effective TCD procedure in determining the transit of microbubbles through a PFO and subsequently in the MCAs.