Aktueller Stellenwert der ultraschallbasierten Rechts-Links-Shunt Diagnostik

Zusammenfassung

Bei der Ursachenabklärung des ischämischen Schlaganfalls gerade jüngerer Patienten wird die „paradoxe Embolie“ über einen Rechts-Links-Shunt als möglicher Mechanismus diskutiert. Die diagnostischen Maßnahmen zur Sicherung eines Shunts sollen die Ursache sichern und eine Therapieentscheidung begründen helfen. Die transösophageale Echokardiografie (TEE) gilt weithin als Standard, weist aber auch Risiken und Fehlbefunde auf. Eine elegante Methode ist die kontrastmittelgestützte transkranielle Dopplersonografie (cTCD). Sie ist als Screeningmethode und zur Kontrolle der Behandlungsergebnisse (z. B. Schirmverschluß) sehr gut geeignet und erreicht hohe Sensitivitätswerte.

Abstract

The clinical approach in young ischaemic stroke patients to find the pathomechanism is focused on paradoxical embolism. Diagnostic examinations to assess a right-left shunt are required in order to initialize therapeutic options. The transesophageal echocardiography (TEE) is the gold standard for the diagnosis of a patent Foramen ovale (PFO) but has some limitations. A simple method is provided by contrast-enhanced transcranial Doppler sonography (cTCD). cTCD serves as a highly sensitive method for shunt screening and for interventional treatment control.

Schlüsselwörter

PFO - cTCD - pardoxe Embolien

Key words

PFO - cTCD - pardoxical embolism

• Literatur

• 1 Calvet D, Mas JL. Closure of patent foramen ovale in cryptogenic stroke: a never ending story. Curr Opin Neurol 2014; 27: 13-19
• 2 Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000; 55: 1172-1179
• 3 Meissner I, Khandheria BK, Heit JA et al. Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study. J Am Coll Cardiol 2006; 47: 440-445
• 4 Agmon Y, Khandheria BK, Meissner I et al. Frequency of atrial septal aneurysms in patients with cerebral ischemic events. Circulation 1999; 99: 1942-1944
• 5 Handke M, Harloff A, Bode C et al. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med 2007; 357: 2262-2268
• 6 Calvet D, Mas JL. Closure of patent foramen ovale in cryptogenic stroke: a never ending story. Curr Opin Neurol 2014; 27: 13-19
• 7 Homma S, Di Tullio MR. Patent foramen ovale and stroke. J Cardiol 2010; 56: 134-141
• 8 Messe SR, Silverman IE, Kizer JR et al. Practice parameter: recurrent stroke with patent foramen ovale and atrial septal aneurysm: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004; 62: 1042-1050
• 9 Almekhlafi MA, Wilton SB, Rabi DM et al. Recurrent cerebral ischemia in medically treated patent foramen ovale: a meta-analysis. Neurology 2009; 73: 89-97
• 10 Fenster BE, Curran-Everett D, Freeman AM et al. Saline contrast echocardiography for the detection of patent foramen ovale in hypoxia: a validation study using intracardiac echocardiography. Echocardiography 2014; 31: 420-427
• 11 Lambertz H, Lethen H Hrsg Transösophageale Echokardiographie. Lehratlas und Atlas zur Untersuchungstechnik und Befundinterpretation. Thieme; 2007
• 12 Mojadidi MK, Roberts SC, Winoker JS et al. Accuracy of transcranial Doppler for the diagnosis of intracardiac right-to-left shunt: a bivariate meta-analysis of prospective studies. JACC Cardiovasc Imaging 2014; 7: 236-250
• 13 Van H, Poommipanit P, Shalaby M et al. Sensitivity of transcranial Doppler versus intracardiac echocardiography in the detection of right-to-left shunt. JACC Cardiovasc Imaging 2010; 3: 343-348
• 14 Consensus Committee of the Ninth International Cerebral Hemodynamic Symposium. Basic identification criteria of Doppler microembolic signals . (The members of the Consensus Committee of the Ninth International Cerebral Hemodynamics Symposium, as selected by the president, Merrill P. Spencer, MD, are Robert G.A. Ackerstaff, MD, PhD; Viken L. Babikian, MD; Dimitrios Georgiadis, MD; David Russell, MD, PhD; Mario Siebler, MD; Merrill P. Spencer, MD; and David Stump, PhD. Stroke 1995; 26: 1123
• 15 Jauss M, Zanette E. Detection of right-to-left shunt with ultrasound contrast agent and transcranial Doppler sonography. Cerebrovasc Dis 2000; 10: 490-496
• 16 Ringelstein EB, Droste DW, Babikian VL et al. Consensus on microembolus detection by TCD. International Consensus Group on Microembolus Detection. Stroke 1998; 29: 725-729
• 17 Nedeltchev K, Mattle HP. Contrast-Enhanced Transcranial Doppler Ultrasound for Diagnosis of Patent Foramen Ovale. In: Baumgartner RW. (ed) Handbook on Neurovascular Ultrasound. Front Neurol Neurosci. Basel: Karger; 2006. 21. 206-215
• 18 Horner S, Niederkorn K, Fazekas F. Patent Foramen Ovale. In: Bartels E, Bartels S, Poppert H. (ed.) New Trends in Neurosonology and Cerebral Hemodynamics – an Update. Perspectives in Medicine. Elsevier; 2012. 1. 228-231
• 19 Plas GJ, Bos J, Velthuis BO et al. Diagnostic yield of external loop recording in patients with acute ischemic stroke or TIA. J Neurol 2015; [Epub ahead of print]
• 20 Furlan AJ, Jauss M. Patent foramen ovale and cryptogenic stroke: the hole story. Stroke 2013; 44: 2676-2678
• 21 Carroll JD, Saver JL, Thaler DE et al Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013; 368: 1092-1100
• 22 Meier B, Kalesan B, Mattle HP et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368: 1083-1091
• 23 Wolfrum M, Froehlich GM, Knapp G et al. Stroke prevention by percutaneous closure of patent foramen ovale: a systematic review and meta-analysis. Heart 2014; 100: 389-395
• 24 Kitsios GD, Thaler DE, Kent DM. Potentially large yet uncertain benefits: a meta-analysis of patent foramen ovale closure trials. Stroke 2013; 44: 2640-2643
• 25 Marchese N, Pacilli MA, Inchingolo V et al. Residual shunt after percutaneous closure of patent foramen ovale with AMPLATZER occluder devices – influence of anatomic features: a transcranial Doppler and intracardiac echocardiography study. EuroIntervention 2013; 9: 382-388
• 26 Sorensen SG, Spruance SL, Smout R et al. Transcranial Doppler quantification of residual shunt after percutaneous patent foramen ovale closure: correlation of device efficacy with intracardiac anatomic measures. J Interv Cardiol 2012; 25: 304-312