cTCD allows estimation of the shunt size by quantification and ca

cTCD allows estimation of the shunt size by quantification and categorization of the contrast shunted. The results are comparable with shunt quantification using cTEE [3], [11], [17], [18], [19], [20] and [21]. Large RLS assessed by cTCD have been reported to be associated with a higher risk of first and recurrent stroke, particularly with cryptogenic stroke [17] and [22]. In contrast, results of a study showed that massive RLS sized ALK inhibitor with TCD

were not an independent risk factor for recurrent stroke [18]. Therefore, the clinical significance of cTCD shunt sizing remains unclear. The impact of cTCD in RLS detection has been studied in a number of conditions other than cerebrovascular disease; however, the grade of evidence from these studies is low to moderate: a significant association was reported between the degree of cTCD sized shunting and the number of signal abnormalities on MRI in asymptomatic sport divers [23]. Divers with RLS show a higher risk of decompression sickness [24]. There is

evidence of an increased prevalence of PFO in patients with migraine with aura [25], supported by cTCD studies [26] and [27]. Furthermore, cTCD has selleck products been described to be useful to detect residual shunting following transcatheter closure of a PFO [28]. Depending on methodological factors, cTCD results vary considerably. Therefore, criteria of the examination technique were established by an International Consensus Meeting. Phospholipase D1 The goal was a standardized approach and minimal variability for RLS detection by cTCD [16]. The examination technique recommended by this Consensus Meeting is summarized in Table 1. Fig. 1 shows a video demonstration of a positive contrast study in a patient with large PFO. Additional data are available also from publications summarizing the impact and technique of cTCD for diagnosis of PFO [29] and [30]. cTCD uses air-containing echo contrast agents (CAs) which normally are

unable to pass the pulmonary capillary bed. The diagnosis of a RLS by cTCD is established if TCD observes microembolic signals after contrast injection. However, the minimal amount of microembolic signals suggestive of a clinically relevant RLS is not established [16]. Different authors require different numbers of microembolic signals for the diagnosis of a PFO. They range from a minimum of one microembolus to more than five microemboli. In addition, the time from contrast injection to signal detection ranges from 6 to 10 cardiac cycles or from 4 s to 24 s [31], [32] and [33]. Most authors used agitated saline solution as contrast agent [4], [18], [33], [34], [35], [36], [37], [38] and [39] or d-galactose Mb solution (Echovist®) [12], [32], [34], [40], [41], [42], [43], [44], [45] and [46]. Only few authors used other agents such as Oxypolygelatine (Gelifundol®, Gelofusin®) [3], [31] and [39].

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