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ORIGINAL RESEARCH article

Front. Neurol.
Sec. Stroke
Volume 15 - 2024 | doi: 10.3389/fneur.2024.1481817
This article is part of the Research Topic Neurosonology in Stroke View all articles

Incorporation of Robotic Automated Transcranial Doppler to Screen for Patent Foramen Ovale (PFO) and Quantify Right to Left Shunt Severity in the Evaluation of Ischemic Stroke Patients for Etiology and PFO Management

Provisionally accepted
Ira Chang Ira Chang *Yasaman Pirahanchi Yasaman Pirahanchi Simon Izaguirre Simon Izaguirre Richard Rodriguez Richard Rodriguez Alyssa Wicknick Alyssa Wicknick
  • Swedish Medical Center (United States), Englewood, Colorado, United States

The final, formatted version of the article will be published soon.

    Background Right to left shunt (RLS) associated with patent foramen ovale (PFO) is common among cryptogenic strokes. Current diagnostic tools have limitations. Transesophageal echocardiography (TTE) is not as sensitive as transthoracic echocardiography (TEE), TEE is invasive, and manual transcranial doppler (TCD) requires trained staff to operate. Robotic automated TCD (raTCD) may be feasible and comparable to manual TCD. The study purpose was to determine the rate of RLS detection using raTCD and combine Spencer Logarithmic Scale (SLS) with the Risk of Paradoxical Embolism (RoPE) to identify patients at risk for PFO. Methods This single center retrospective cohort study included adult patients (≥18 y/o admitted 12/2021-12/2022 with a stroke or transient ischemic attack. Those with no bone window or stroke mimics were excluded. Patients with a RLS on raTCD received a second scan at physician’s discretion The SLS combined with RoPE score was used to generate a modified screening PFO-Associated Stroke Causal Likelihood (msPASCAL). Results Of 212 patients who received raTCD, the mean age was 56, 14% were > 65 y/o, most were White (72%), predominantly male (59%), 52% had cryptogenic strokes, and 59% had an RLS. Most patients were able to Valsalva (89%) during raTCD. Of those with a RLS, 56% had a SLS of 1-2, and 44% had a SLS of 3-5. There were no significant differences in characteristics by SLS. Most patients with SLS grade 1-2 were classified using msPASCAL as Unlikely to have PFO (n=55, 44%). A smaller number of large SLS grade 3-5 were considered as Probable for having a PFO associated stroke. The rest of the large SLS grade RLS patients were classified as Possible PFO (n=38, 30.4%). Eight patients with positive RLS on raTCD, had a negative TEE with bubble. Most had small RLS on raTCD (n=5, 63%) or could not Valsalva due to sedation (n=6, 75%). Discussion This study supports the feasibility of utilizing raTCD for RLS detection. The modified screening PASCAL classification can be generated for RLS patients and may be used to guide subsequent evaluation and management.

    Keywords: robotic automated transcranial doppler, patent foramen ovale, Right to left shunt, ischemic stroke, transesophageal echocardiography, transthoracic echocardiography

    Received: 16 Aug 2024; Accepted: 18 Dec 2024.

    Copyright: © 2024 Chang, Pirahanchi, Izaguirre, Rodriguez and Wicknick. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

    * Correspondence: Ira Chang, Swedish Medical Center (United States), Englewood, 80113, Colorado, United States

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