Introduction: In patients with cryptogenic strokes, the discovery of a right to left shunt (RLS) may change management. Recent data suggest that transcranial doppler with agitated saline bubble study (TCD) has a higher sensitivity in RLS detection than transesophageal echo (TEE). We evaluated whether or not TCD could guide optimization of stroke care as indicated by a change in stroke management.
Methods: We reviewed 370 inpatient and outpatient TCD studies performed at Cedars-Sinai Medical Center between May 2013 and May 2015. We recorded TCD, TEE and neurology consult results. Spencer grade (both at rest and with Valsalva) and change in management were determined. A change in management was classified as a change in medication, additional diagnostic testing ordered, or consideration of PFO closure.
Results: We found 42 patients with both TEE and TCD. Patients were negative for shunt on both TEE and TCD (13); positive both on TEE and TCD (15); positive for right-to-left shunt on TEE and negative on TCD (1); and negative on TEE, but positive on TCD (13).
Average age was 46.2 years, ranging from 28 to 67 years. Seven of 13 patients had a change in management after discovery of the RLS on TCD: 4 PFO closure through trial enrollment; 2 initiated on anticoagulation; 1 hypercoagulable work up. Of the 6 patients without change in management, all had a Spencer grade of 2 or less.
Conclusion: TCD is a sensitive and reliable, non-invasive study to detect RLS. The ability to perform a Valsalva maneuver accounts for a higher sensitivity for RLS detection. Given the superior sensitivity over TEE and potential to change management, TCD should be the preferred screening test for RLS in cryptogenic stroke patients.